Direct sodium removal method, solution and apparatus to reduce fluid overload in heart failure patients

ABSTRACT

A Direct Sodium Removal method, apparatus and solution for treating patients in heart failure, and having a glomerular filtration rate greater than 15 mL/min/1.73 m2, or residual kidney function corresponding to normal to CKD Stage 4, is provided in which a no or low sodium DSR infusate is administered to the peritoneal cavity for a predetermined dwell period and then removed, thereby removing sodium from the body. The resulting elimination of fluid from the patient by i) functioning of the kidneys through urination and ii) direct removal of osmotic ultrafiltrate from the peritoneal cavity, restores serum sodium concentrations to healthy levels and thereby reduces fluid overload in the patient.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of priority of U.S. ProvisionalApplication Ser. No. 62/510,652, filed May 24, 2017, the entire contentsof which are incorporated herein by reference.

FIELD OF THE INVENTION

The present invention relates generally to use of a no or low sodiuminfusate that is administered to a patient's peritoneal cavity todirectly remove sodium, and thereby fluid from the body to alleviatefluid overload in heart failure patients with residual renal function,hereinafter, a DSR infusate. The methods, DSR infusate and apparatuswork to remove excess fluid through the removal of sodium. Sodium ismoved to the peritoneal cavity through one or both of: 1)ultrafiltration and/or 2) diffusion down a steep concentration gradient,from where it is subsequently eliminated. Fluid is eliminated from thebody to maintain a relatively stable serum sodium concentration, by oneor both of: 1) inducing osmotic ultrafiltration to move fluid from thepatient's body into the peritoneal cavity, from where it is eliminatedand/or 2) enhancing the excretion of excess fluid via the kidneysthrough urination.

BACKGROUND

Patients suffering from any of a number of forms of heart failure areprone to the accumulation of additional sodium in body tissues andresultingly, increased fluid in the body. For example, in congestiveheart failure, due to dysfunction of the left side or right side of theheart, or both, the body is unable to pump blood with normal efficiency,leading to the reduction in systemic circulation that can result inretention of sodium and stasis or pooling of blood or fluid in the lungsor liver, edema and/or cardiac hypertrophy.

The Centers for Disease Control and Prevention (CDC) estimates thatabout 5.7 million people in the United States suffer from some form ofheart failure. Heart failure is generally categorized into fourdifferent stages with the most severe being end stage heart failure. Endstage heart failure may be diagnosed where a patient has heart failuresymptoms at rest in spite of medical treatment. Patients may havesystolic heart failure, characterized by decreased ejection fraction. Inpatients with systolic heart failure, the walls of the ventricle areweak and do not squeeze as forcefully as in a healthy patient.Consequently, during systole a reduced volume of oxygenated blood isejected into circulation, a situation that continues in a downwardspiral until death. Patients alternatively may have diastolic heartfailure, in which stiffened or thickened myocardium makes it difficultfor the affected heart chamber to fill with blood. A patient diagnosedwith end stage heart failure has a one-year mortality rate ofapproximately 50%.

Renal failure, also referred to as chronic kidney disease (“CKD”), isdiagnosed by blood tests that measure blood urea nitrogen (“BUN”) andcreatinine, enabling estimation of glomerular filtration rate (“GFR”).GFR is an overall index of kidney function that is calculated by any ofa number of well-known formulae, such as CKD-EPI creatinine equation(2009) or CKD-EPI creatinine-cystatin equation (2012) and takes intoaccount a patient's serum creatinine, age, gender and race. For example,the GFR may be computed using the CKD-EPI creatinine equation (2009) asfollows:

eGFR=141×min(S _(Cr)/κ,1)^(α)×max(S_(Cr)/κ,1)^(−1.209)×0.993^(Age)×1.018 [if female]×1.159 [if Black]

-   -   wherein:    -   eGFR (estimated glomerular filtration rate)=mL/min/1.73 m²    -   S_(Cr) (standardized serum creatinine)=mg/dL    -   κ=0.7 (females) or 0.9 (males)    -   α=−0.329 (females) or −0.411 (males)    -   min=indicates the minimum of S_(Cr)/κ or 1    -   max=indicates the maximum of S_(Cr)/κ or 1    -   age=years        The foregoing equation is available on the National Kidney        Foundation website at        https://www.kidney.org/content/ckd-epi-creatinine-equation-2009.

Generally, assessment of the severity of CKD is based on the computedGFR value in conjunction with the following table:

GFR Stage Description (mL/min/1.73 m²⁾ At increased Risk factors forkidney disease >90 risk (e.g., diabetes, high blood pressure, familyhistory, older age, ethnic group) 1 Kidney damage with normal kidney ≥90function 2 Kidney damage with mild loss of 89 to 60 kidney function 3aMild to moderate loss of kidney 59 to 44 function 3b Moderate to severeloss of kidney 44 to 30 function 4 Severe loss of kidney function 29 to15 5 Kidney failure  <15

Typically, a patient with severely reduced kidney function, generallystage 5, will receive dialysis to remove metabolic waste from the bloodwhen the kidneys can no longer do so adequately. Dialysis may beaccomplished using either an extracorporeal machine or peritonealdialysis. In the first option, the patient is coupled to a hemodialyzer,in which case blood is routed from the body to an extracorporealmachine, cleansed, and then returned to the patient's body. Inperitoneal dialysis, a cleansing fluid or dialysate is infused into thepatient's abdomen, where it causes metabolic waste to pass from theabdominal arteries and veins into the dialysate for a specified periodof time, e.g., 30-45 minutes, after which the dialysate is drained fromthe abdomen and discarded. Typically, the patient may repeat thisprocess between three and five times each 24-hour period.

Low sodium dialysates are known for use in patients with end-stage renaldisease requiring dialysis to treat CKD. For example, U.S. Pat. No.5,589,197 to Shockley et al. describes a dialysate for use in peritonealdialysis wherein the sodium concentration is between about 35 to 125meq/L. As explained in that patent, the sodium concentration in thesolution may be decreased to a level below the patient's plasmaconcentration of sodium, thus causing sodium to be transported from thecirculation to the peritoneal cavity. Unfortunately, problems wereencountered with such low sodium dialysates, including symptomatic dropsin blood pressure, and in some cases dialysis disequilibrium syndrome, apotentially fatal complication resulting in cerebral edema, coma anddeath. See, e.g., Nakayma, Clinical Effect of Low Na ConcentrationDialysate (120 mEq/L) for CAPD Patients, PD Conference, San See, e.g.,Zepeda-Orozco D, Quigley R., Dialysis disequilibrium syndrome, PediatricNephrology (Berlin, Germany) 2012; 27(12):2205-2211.

In view of the past experience with low sodium dialysates, people withend-stage kidney disease who receive dialysis on a regular basis rely ontherapy to optimize salt and water levels. The reported current averageconcentration of sodium in dialysate is generally about 132 mMol/L. See,e.g., Hecking M, Kainz A, Horl W H, Herkner H, Sunder-Plassmann G.,Sodium setpoint and sodium gradient: influence on plasma sodium changeand weight gain. American Journal of Nephrology 2011; 33(1):39-48; McCausland F R, Brunelli S M, Waikar S S., Dialysate sodium, serum sodiumand mortality in maintenance hemodialysis. Nephrology DialysisTransplantation 2012; 27(4):1613-8.

Decades of experience with dialysate sodium concentrations that arehigher than patients' blood sodium levels show that such dialysatesfacilitate fluid removal without removal of sodium during dialysis andimprove the likelihood of maintaining normal BP and heart functionduring dialysis. However, higher sodium levels also result in people onhemodialysis often dialyzing with a positive sodium gradient betweentheir blood and the dialysate. See, e.g., Munoz Mendoza J, Sun S,Chertow G, Moran J, Doss S, Schiller B., Dialysate sodium and sodiumgradient in maintenance hemodialysis: a neglected sodium restrictionapproach?, Nephrology Dialysis Transplantation 2011; 26(4):1281-7.Accordingly, patients often gain sodium by the end of a dialysissession, resulting in increased thirst, fluid consumption andhypertension. As such, the net result for patients having multipleweekly hemodialysis sessions is chronic sodium and water overload.

Applicants have observed that eliminating fluid overload is a keyclinical objective in heart failure, and that fluid overload can lead toserious clinical complications including dyspnea. Achieving effectivereduction of fluid requires the elimination of sodium from the body, asthe body will act to maintain a constant serum osmolality and tomaintain its sodium levels, as described for example, in Guyton & Hall,Textbook of Medical Physiology. Accordingly, it would be desirable todevelop a method for using no or low sodium infusates to remove sodiumand thereby fluid from the patient to treat fluid overload in heartfailure patients.

SUMMARY OF THE INVENTION

The present invention is directed to methods of treating fluid overloadin heart failure patients with residual renal function using a no or lowsodium DSR infusate administered to the peritoneal cavity to removesodium and thereby fluid from the patients' body to alleviate fluidoverload. Sodium is moved to the peritoneal cavity through one or bothof: 1) ultrafiltration and/or 2) diffusion down a steep concentrationgradient, from where it is subsequently eliminated. Fluid is eliminatedfrom the body to maintain a relatively stable serum sodiumconcentration, by one or both of: 1) inducing osmotic ultrafiltration tomove fluid (osmotic ulfiltrate) from the patient's body into theperitoneal cavity, from where it is eliminated and/or 2) enhancing theexcretion of excess fluid via the kidneys through urination. As such,the present invention eliminates sodium from the body and thereby fluidto maintain relatively stable serum sodium concentrations, reducingfluid overload and edema, while preventing hyponatremia.

In accordance with the principles of the present invention, a patientsuffering from heart failure is treated (either intermittently orcontinuously) with a low sodium or no sodium DSR infusate administeredto the peritoneal cavity. The DSR infusate, which in an exemplary formmay comprise a D-10 dextrose solution, i.e., 10 grams dextrose per 100ml of aqueous solution, is allowed to remain in the peritoneal cavityfor a predetermined period before it is removed, and then is extractedtogether with sodium that moves from the patient's body into theperitoneal cavity and the osmotic ultrafiltrate. The proposed directsodium removal (“DSR”) method constitutes a radical departure fromconventional peritoneal dialysis, in that it is designed specifically totreat fluid overload in heart failure patients, rather than attemptingto remove toxins and accumulated metabolic byproducts by cleansing thetissues with a dialysate, as in conventional peritoneal dialysis.

In accordance with one aspect of the invention, the inventive DSRmethod, infusates and apparatus are expected to be suitable for use inheart failure patients suffering from fluid overload who generallydemonstrate a GFR value greater than 15 mL/min/1.73 m² and shouldexhibit kidney function from normal to CKD Stage 4. In patients with CKDof Stage 5 or GFR<15 ml/min/1.73 m², use of a no or low sodium DSRinfusate with volumes adequate for dialysis would result in dangerous orterminal hyponatremia and reduction in plasma volume leading tohemodynamic collapse. Conversely, use of small volumes of a no or lowsodium DSR infusate to avoid hyponatremia in these patients who neededdialysis would not provide sufficient removal of waste products, and mayresult in uremia. In other words, patients suitable for direct sodiumremoval using the method of the present invention would be patients notnormally eligible for dialysis for the purpose of CKD treatment.

In particular, due to concern regarding symptomatic blood pressure drop,as well as hyponatremia and related effects, patients normally eligiblefor dialysis with end-stage kidney insufficiency, exhibiting CKD ofStage 5 or GFR less than or equal to 15 mL/min/1.73 m² specificallyshould be excluded from the pool of patients eligible for use with theDSR methods of the present invention.

The proposed methods of using a no or low sodium DSR infusate inaccordance with the principles of the present invention may beaccomplished with the implantable pump system described incommonly-assigned U.S. Patent Application Publication No.US2014/0066841, the contents of which are incorporated herein byreference. That published application describes a system for ambulatoryperitoneal dialysis in which a patient infuses a dialysate into theabdomen, and after a predetermined time and at predetermined intervals,an implantable pump transfers volumes of dialysate to the patient'sbladder, where it may be excreted through urination. In accordance withthe principles of the present invention, the process is performed not toaddress or even principally address CKD. Instead, the process isperformed with a no or low sodium DSR infusate to remove sodium in heartfailure patients suffering from fluid overload who retain residual renalfunction. As a result, fluid is removed from the body through i)urination (as a result of the remaining kidney function) and ii) directremoval of the osmotic ultrafiltrate, to restore serum sodiumconcentrations and reduce fluid overload and edema, while preventinghyponatremia.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A is a perspective view of an exemplary system for implementingthe methods of the present invention in a heart failure patient withresidual renal function suffering from fluid overload.

FIG. 1B is a plan view of selected components of the system of FIG. 1Aas implanted in a patient.

FIG. 1C is a plan view of selected components of an alternativeembodiment of an exemplary system for practicing the methods of thepresent invention.

FIG. 1D illustrates steps of an exemplary method in accordance with theprinciples of the present invention using the system of FIGS. 1A-1C.

FIGS. 2A and 2B are, respectively, side view and perspective detailedviews of an exemplary embodiment of a peritoneal catheter suitable foruse with system of FIG. 1, in which FIG. 2B corresponds to detail region2B of FIG. 2A.

FIGS. 3A and 3B are, respectively, side and perspective views,respectively, of first and second embodiments of bladder catheterssuitable for use with the system of FIG. 1.

FIG. 4 is a schematic diagram of the electronic components of anexemplary embodiment of the implantable device.

FIGS. 5A and 5B are, respectively, a perspective view of the implantabledevice with the housing shown in outline and a perspective view of theobverse side of the implantable device with the housing and low waterpermeable filler removed.

FIGS. 6A, 6B, 6C and 6D are, respectively, an exploded perspective viewof the drive assembly of the implantable device; front and plan views ofthe upper housing; and a perspective view of the manifold of anexemplary embodiment of the implantable device.

FIGS. 7A and 7B are, respectively, perspective and top views of thehandpiece portion of an exemplary charging and communication system foruse in practicing the methods of the present invention;

FIG. 8 is a schematic diagram of the electronic components of anexemplary embodiment of the charging and communication system for use inpracticing the methods of the present invention.

FIG. 9 is a schematic diagram of the software implementing themonitoring and control system for use in practicing the methods of thepresent invention.

FIG. 10 is a screen display of the main screen that is displayed to aphysician running monitoring and control software.

FIG. 11 is a screen display of the selection of the “Smart Charger”submenu item in FIG. 10.

FIG. 12 is a screen display of the selection of the “Download” menu itemin FIG. 10 and “Log Files” submenu item.

FIG. 13 is a screen display of the selection of the “Pump Settings” menuitem in FIG. 10 and “Fluid Transport” submenu item.

FIG. 14 is a screen display of the selection of the “Test” menu item inFIG. 11 and “Manual Test Run” submenu item.

FIGS. 15A, 15B and 15C are graphs depicting the results of testing ofthe inventive DSR method on an initial group of five animals.

FIGS. 16A to 16F are graphs depicting the results of testing of theinventive DSR method on a follow-up group of ten animals.

FIGS. 17A to 17C are graphs depicting changes to blood volume, red bloodcount, and plasma volume for a sub-group of the second group of animalsafter consecutive applications of the inventive DSR method.

FIG. 18 is a graph depicting the changes to serum sodium level foranimals in the sub-group of the second group of animals afterconsecutive applications of the DSR method.

DETAILED DESCRIPTION OF THE INVENTION

The present invention is directed to methods of treating fluid overloadin various forms of heart failure, such as left heart or right heartdysfunction. In accordance with the principles of the present invention,a heart failure patient with residual renal function suffering fromfluid overload is treated with a no or low sodium DSR infusateadministered to the peritoneal cavity. The low sodium concentration inthe DSR infusate causes sodium and fluid (osmotic ultrafiltrate) to passfrom the patient's body into the peritoneal cavity. The DSR infusate isallowed to remain, or dwell, in the peritoneal cavity for apre-determined period before it is removed, together with the extractedsodium and the osmotic ultrafiltrate. Removal of the sodium-laden DSRinfusate and osmotic ultrafiltrate from the peritoneal cavity may beperformed using an implantable system, such as the Alfapumpcommercialized by Sequana Medical AG, Zurich, Switzerland.

As used in this disclosure, a no or low sodium DSR infusate has a sodiumcontent of less than 120 meq/L, more preferably, less than 35 meq/L, andincludes infusates having virtually zero concentration of sodium.Accordingly, the fluid overload treatment methods of the presentinvention specifically contemplate use of the inventive methods in heartfailure patients having residual kidney function, and thus not in kidneyfailure. As used in this specification, residual kidney functioncorresponds to patients having a GFR value greater than 15 ml/min/1.73m² or kidney function from normal to CKD of Stage 4.

Exemplary DSR infusate formulations in accordance with the principles ofthe present invention include D-0.5 to D-50 solutions, i.e., from 0.5 to50 grams of dextrose per 100 ml of aqueous solution; Icodextrinsolutions having from 0.5 to 50 grams of icodextrin per 100 ml ofaqueous solution; high molecular weight glucose polymer solutions(weight average molecular weight Da>10,000) having from 0.5 to 50 gramsof high molecular weight glucose polymer per 100 ml of aqueous solution,and combinations thereof. The aqueous solution includes at leastpurified water, and may in addition include electrolytes such as lowamounts of magnesium or calcium salts, preservatives, ingredients havingantimicrobial or antifungal properties, or buffering materials tocontrol pH of the infusate. It is expected that Icodextrin, a highmolecular weight glucose polymer, or other high molecular weight glucosepolymer (weight average molecular weight, Da>10,000) may be preferableto dextrose because it has been observed to experience a lower rate ofuptake when employed in a peritoneal dialysis setting, and thus mayprovide reduced serum glucose concentrations compared to adextrose-based DSR solutions.

It is expected that the no or low sodium DSR infusate described hereinshould not be used on all heart failure patients with fluid overload,particularly those with little residual renal function, as the resultcould be fatal. For example, it is expected that use of the methods andDSR infusate of the present invention on heart failure patients having aGFR value lower than 15 or CKD of Stage 5, may result in severehyponatremia and hypotension. Accordingly, for safety reasons, patientssuffering from heart failure but also in kidney failure, or with a GFRless than or equal to 15 ml/min/1.73 m² or CKD of Stage 5 arecontraindicated for use with the methods of treatment described herein.

Although it is contemplated that the inventive methods and DSR infusatemay be used to treat fluid overload in heart failure with conventionalperitoneal infusion and drainage techniques, it is expected thatpractice of the present invention may be particularly advantageouslyimplemented using the implantable pump system offered by the assignee ofthe present application. Specifically, the Alfapump system, offered bySequana Medical AG, Zurich, Switzerland, is well suited for treatingheart failure using a peritoneal infusion mode of operation. Inaccordance with one aspect of the present invention, the no or lowsodium DSR infusate is introduced into the peritoneal cavity, where thezero or low sodium concentration causes sodium and osmotic ultrafiltrateto pass from the patient's body into the peritoneal cavity. Atpredetermined times after infusion of the DSR infusate, and forpredetermined intervals, the implantable pump may be activated, inaccordance with a clinician's programmed instructions, to pump thesodium-laden DSR infusate and osmotic ultrafiltrate to the patient'sbladder at a predetermined flow rate. Removal of sodium from the bodyleads to the removal of fluid by i) the functioning kidneys throughurination and ii) accumulation of osmotic ultrafiltrate directly intothe peritoneal cavity, which is then removed to the bladder via theimplantable pump. In this manner, sodium and fluid is removed, whilemaintaining appropriate and stable serum sodium concentrations. Further,it is expected that after a DSR session, fluid will continue toaccumulate in the peritoneal cavity as a result of the fluid overload,and the implantable pump may be programmed to pump such fluid to thebladder on a regular basis. The fluid accumulating in the peritonealcavity is expected to contain sodium so the removal of such fluid to thebladder will lead to a further reduction of fluid overload in thesepatients.

The methods of the present invention therefore provide a method ofcontrolling fluid overload and edema in heart failure patients whilepermitting such patients to experience a more normal lifestyle,untethered from frequent visits to a hospital or other medical facility.Advantageously, because the methods of the present invention lead to areduction in fluid volume, the patient not only may experience improvedcomfort and lifestyle, but also forestalled co-morbidities, such asadvancing chronic kidney disease and progressive heart failure.

An exemplary implantable system for practicing the method of the presentinvention is described in greater detail below as including animplantable pump that is specially configured to move fluid out of theperitoneal cavity and into the bladder, and that includes a plurality ofsensors for monitoring and recording operating parameters relevant tothe health of the patient. An externally held charging and communicationsystem periodically charges and communicates with the implantabledevice, and downloads from the device the recorded operating parameters.Monitoring and control software on the treating physician's computerreceives the recorded operating parameters from the charging andcommunication system, and allows the physician to modify the operationof the implantable device based on the physician's perception of thepatient's health as reflected in the recorded operating parameters.Optionally, the monitoring and control software may be configured toalert the physician as to a prediction or detection of infection, heartfailure decompensation or other clinical events based on the recordedoperating parameters. The implantable device optionally may also includeone or more ultraviolet (UV) sources configured to inhibit infection.

Overview of an Exemplary System for Implementing the Inventive Method

Referring to FIG. 1A, an overview of selected components of exemplarysystem 10 for use in practicing the methods of the present invention isprovided. In FIG. 1A, components of the system are not depicted to scaleon either a relative or absolute basis. System 10 comprises implantabledevice 20, external charging and communication system 30, software-basedmonitoring and control system 40, and optionally, DSR infusate reservoir45. In the illustrated embodiment, monitoring and control system 40 isinstalled and run on a conventional laptop computer, tablet orsmartphone, as may be used by the patient's physician. During patientvisits, charging and communication system 30 may be coupled, eitherwirelessly or using a cable, to monitoring and control system 40 todownload for review data stored on implantable device 20, or to adjustthe operational parameters of the implantable device. Monitoring andcontrol system 40 also may be configured to upload and store dateretrieved from charging and communication system 30 to a remote serverfor later access by the physician or charging and communications system30.

Implantable device 20 comprises an electromechanical pump having housing21 configured for subcutaneous implantation. As described in furtherdetail below with reference to FIG. 1C, implantable device 20 mayinclude an electrically-driven mechanical gear pump as well as secondpump connector 22 and first pump connector 24 configured to reduce therisk of improper installation and inadvertent disconnection, and mayadditionally include distinct cross-sections that further reduce therisk of improper installation. Catheter 46 and bladder catheter 25 arecoupled to pump housing 21 and in some embodiments may be coupled topump housing 21 using first pump connector 24. Peritoneal catheter 23 iscoupled to pump housing 21 and may be coupled to pump housing 21 usingsecond pump connector 22. DSR infusate is provided to the patient'speritoneal cavity from reservoir 45. Peritoneal catheter 23 comprises atube having a first (proximal) end configured to be coupled to pumphousing 21 and a second (distal) end configured to be positioned in theperitoneal cavity. Bladder catheter 25 comprises a tube having a first(proximal) end configured to be coupled to pump housing 21 and a second(distal) end configured to be inserted through the wall of, and fixedwithin, a patient's bladder. In a preferred embodiment, both cathetersare made of medical-grade silicone and include polyester cuffs at theirdistal ends (not shown) to maintain the catheters in position.

Optional reservoir 45 is configured to deliver the no or low sodium DSRinfusate to the patient's peritoneal cavity via catheter 46, which mayhave similar construction to the peritoneal catheter described furtherbelow with respect to FIGS. 2A-2B. In embodiments described furtherbelow with reference to FIG. 1B, the proximal end of catheter 46 may beconfigured to be removably coupled to external reservoir 45 via anappropriate coupling allowing the patient to easily exchange a depletedreservoir for a fresh one, and the distal end of catheter 46 may beconfigured for implantation in the patient's peritoneal cavity, with atissue cuff (not shown) to promote tissue ingrowth at the point at whichcatheter 46 crosses the wall of the patient's skin and/or peritoneum.The distal end of catheter 46 may have a plurality of holes or aperturesdefined therein, like those discussed below with reference to FIG. 2B.Reservoir 45 may deliver the DSR infusate to the peritoneal cavity byany suitable mechanism, such as gravity or by operation of anextracorporeal pump (not shown). For example, an external pump may beused to facilitate DSR infusate flow from the reservoir 45 to theperitoneal cavity, or the reservoir may be physically raised above thelevel of the peritoneal cavity such that gravity draws the DSR infusateinto the peritoneal cavity via catheter 46.

In the embodiment of FIG. 1C, the distal end of reservoir catheter 46′instead may be attached to first pump connector 24 of implantable device20, and implantable device 20 may be configured to pump the DSR infusatefrom reservoir 45 into the peritoneal cavity via reservoir catheter 46′and peritoneal catheter 23. In such embodiments, reservoir 45 may beexternal or implantable, and implantable device 20 further may includeone or more passive or active valves to prevent fluid from leaking fromthe reservoir into the bladder and from being pumped out of the bladderand into the peritoneal cavity at the same time that fluid is pumpedfrom the reservoir and into the peritoneal cavity. The passive or activevalves may also prevent sodium-laden DSR infusate and osmotic filtratefrom being pumped out of the peritoneal cavity into the reservoir at thesame time that such fluid is pumped from the peritoneal cavity into thebladder. Alternatively, the one or more passive or active valves may bepositioned within reservoir catheter 46′, peritoneal catheter 23 and/orbladder catheter 25.

Preferably, implantable device 20 is configured to move the sodium-ladenDSR infusate and osmotic ultrafiltrate from the peritoneal cavity to thebladder in quantities, intervals and flow rates selected to providesufficient time for the targeted amount of sodium to accumulate in theDSR infusate resulting in a reduction of sodium in the body leading tothe removal of fluid by i) the functioning kidneys (through urination)and ii) direct removal to the bladder of the osmotic ultrafiltrate fromthe peritoneal cavity thereby reducing fluid overload and edemaresulting from heart failure. Treatment algorithms may be developed withdifferent formulations and volumes of no or low sodium DSR infusates,different lengths of dwell period and different rates of removal to thebladder. In general, pumping for short but frequent intervals isexpected to inhibit the accumulation of material on the interior lumensof catheters 23 and 25, and reduce the risk of tissue ingrowth. Thefluid circuit of implantable device 20 may be configured to provide anaverage flow rate of about 1-2.5 liters/hour, although much higher andlower flow rates are possible if needed. As described in detail below,the pumping time, flow rate and volume, including the time the DSRinfusate is allowed to remain in the peritoneal cavity, may beprogrammed by the physician using monitoring and control system 40 asrequired for a specific patient.

Implantable device 20 may include pressure sensors that monitor pressurein one or both of the peritoneal cavity and the bladder, such that fluidis pumped from the peritoneal cavity to the bladder if theintra-abdominal pressure exceeds a limit determined by the physician.Alternatively or in addition, the output of the pressure sensors maycause pumping of fluid into the bladder to be disabled until the bladderis determined to have sufficient space to accommodate additional fluid.For patient comfort, implantable device 10 optionally may be programmednot to pump at night or when an accelerometer included in theimplantable device indicates that the patient is asleep (and thusunlikely to be able to void the bladder). Implantable device 20preferably includes multiple separate fail-safe mechanisms, to ensurethat urine cannot pass from the bladder to the peritoneal cavity throughthe pump, thereby reducing the risk of transmitting infection.

Still referring to FIG. 1A, the external charging and communicationsystem 30 of the exemplary system, in a preferred form, includes base 31and handpiece 32. In this embodiment, handpiece 32 contains acontroller, a radio transceiver, an inductive charging circuit, abattery, a quality-of-charging indicator and a display, and is removablycoupled to base 31 to recharge its battery. Base 31 may contain atransformer and circuitry for converting conventional 120V or 220-240Vservice to a suitable DC current to charge handpiece 32 when coupled tobase 31. In alternative embodiments, handpiece 32 may include suchcircuitry and a detachable power cord, thereby permitting the handpieceto be directly plugged into a wall socket to charge the battery. In apreferred embodiment, each of implantable device 20 and handpiece 32includes a device identifier stored in memory, such that handpiece 32provided to the patient is coded to operate only with that patient'sspecific implantable device 20.

Handpiece 32 preferably includes housing 33 having multi-function button34, display 35, a plurality of light emitting diodes (LEDs, not shown)and inductive coil portion 36. Multi-function button 34 provides thepatient the ability to issue a limited number of commands to implantabledevice 20, while display 35 provides visible confirmation that a desiredcommand has been input; it also displays battery status. Inductive coilportion 36 houses an inductive coil that is used transfer energy fromhandpiece 32 to recharge the battery of implantable device 20. The LEDs,which are visible through the material of housing 33 when lit, may bearranged in three rows of two LEDs each, and are coupled to the controlcircuitry and inductive charging circuit contained within handpiece 32.The LEDs may be arranged to light up to reflect the degree of inductivecoupling achieved between handpiece 32 and implantable device 20 duringrecharging of the latter. Alternatively, the LEDs may be omitted and ananalog display provided on display 35 indicating the quality ofinductive coupling.

Control circuitry contained within handpiece 32 is coupled to theinductive charging circuit, battery, LEDs and radio transceiver, andincludes memory for storing information from implantable device 20.Handpiece 32 also preferably includes a data port, such as a USB port,that permits the handpiece to be coupled to monitoring and controlsystem 40 during visits by the patient to the physician's office.Alternatively, handpiece 32 may include a wireless chip, e.g.,conforming to the Bluetooth or IEEE 802.11 wireless standards, therebyenabling the handpiece to communicate wirelessly with monitoring andcontrol system 40, either directly or via the Internet.

Monitoring and control system 40 is intended primarily for use by thephysician and comprises software configured to run on a conventionalcomputer, e.g., a laptop as illustrated in FIG. 1A or tablet orsmartphone. The software enables the physician to configure, monitor andcontrol operation of charging and communication system 30 andimplantable device 20. The software may include routines for configuringand controlling pump operation, such as a target amount of fluid to movedaily or per motor actuation, intervals between pump actuation, andlimits on peritoneal cavity pressure, bladder pressure, pump pressure,and battery temperature. System 40 also may provide instructions toimplantable device 20 via charging and control system 30 to controloperation of implantable device 20 so as not to move fluid duringspecific periods (e.g., at night) or to defer pump actuation if thepatient is asleep. System 40 further may be configured, for example, tosend immediate commands to the implantable device to start or stop thepump, or to operate the pump in reverse or at high power to unblock thepump or associated catheters. The software of system 40 also may beconfigured to download real-time data relating to pump operation, aswell as event logs stored during operation of implantable device 20.Based on the downloaded data, e.g., based on measurements made of thepatient's intra-abdominal pressure, respiratory rate, and/or fluidaccumulation, the software of system 40 optionally may be configured toalert the physician to a prediction or detection of heart failuredecompensation and/or a change in the patient's health for which anadjustment to the flow rate, volume, time and/or frequency of pumpoperation may be required. Finally, system 40 optionally may beconfigured to remotely receive raw or filtered operational data from apatient's handpiece 32 over a secure Internet channel.

Turning now to FIGS. 1B-1D, various configurations of implantable device20 and optional DSR infusate reservoir 45 are now described. Methods ofusing system 10 in accordance with the present invention to treat aheart failure patient suffering from fluid overload are provided withreference to FIG. 1D.

Referring now to FIG. 1B, an exemplary use of implantable device 20 forimplementing the methods of the present invention is described. Device20 is implanted subcutaneously, preferably outside of the patient'speritoneal cavity 11 as defined by peritoneal membrane 12, but beneathskin 13 so that the device may readily be charged by, and communicatewith, charging and communication system 30 illustrated in FIG. 1A.Device 20 is coupled via appropriate connectors (not shown) toperitoneal catheter 23 and bladder catheter 25. Peritoneal catheter 23is configured for implantation in the patient's peritoneal cavity 11 andpreferably includes apertures 53 such as described in further detailbelow with reference to FIGS. 2A-2B. Bladder catheter 25 is configuredfor implantation in the patient's bladder 13 and preferably includes ananchor to secure the outlet end of the catheter within the bladder 13,such as described in further detail below with reference to FIGS. 3A-3B.

Optional DSR infusate reservoir 45 is positioned outside of the body,coupled to the peritoneal cavity via catheter 46. Catheter 46 is coupledto reservoir 45 via connector 47, which is configured so as to allow thepatient to periodically replace reservoir 45 with ease. Catheter 46preferably includes apertures 53′, which may be similar in dimension anddensity to apertures 53, and which allow the DSR infusate to flow intothe peritoneal cavity 11 in a relatively diffuse manner. Optionalexternal pump 48 may be configured to cause the DSR infusate to flowfrom reservoir 45 into the peritoneal cavity 11 at a desired rate. Forexample, reservoir 45 may be positioned on a belt (not shown) that isworn around the patient's waist and includes pump 48. Pump 48 may beconfigured to communicate wirelessly with implantable device 20 so as tocoordinate delivery of DSR infusate into the patient's peritonealcavity.

In an alternative embodiment, DSR infusate reservoir 45 is positioned ata level above the peritoneal cavity 11 such that gravity causes the DSRinfusate to flow from reservoir 45 into the peritoneum at a desiredrate. In yet another embodiment, a pressurized container may beconfigured in combination with a controlled valve or a calibrated flowrestriction device to deliver a predefined flow rate without the use ofa pump. In this manner the delivery of the DSR infusate may be passivewithout the need for electronics or a pump. Delivery of a predefinedamount of the DSR infusate may be recognized by the implantable devicebased on pressure increase within the peritoneal cavity, use of a flowmeter, or other suitable measurement system.

In the embodiments discussed above, reservoir 45 preferably provides DSRinfusate to peritoneal cavity 11 in a volume, at a rate, and with afrequency suitable to sufficiently fill the peritoneal cavity with theDSR infusate to treat or alleviate the fluid overload of the heartfailure patient.

Alternatively, as illustrated in FIG. 1C, optional DSR infusatereservoir 45 may be positioned outside of the patient's body, e.g.,using a belt or harness, and may be coupled to implantable device 20 viacatheter 46′ and connector 47. Implantable device 20 is configured topump DSR infusate into peritoneal cavity 11 from reservoir 45 viacatheters 46′ and 23, and then at a later time to pump the sodium-ladenDSR infusate and osmotic ultrafiltrate from peritoneal cavity 11 intobladder 13 via catheters 23 and 25. Specifically, first pump connector24 of implantable device 20 comprises a first valve 49′ to whichcatheter 25 is connected and a second valve 49 to which catheter 46′ isconnected. Second pump connecter 22 of implantable device 20 is directlyconnected to catheter 23. During pumping operations, implantable device20 controls valves 49 and 49′ so as to prevent fluid from beinginadvertently pumped from the bladder into the peritoneal cavity or fromthe peritoneal cavity into the reservoir. For example, to pump fluidinto the peritoneal cavity 11 from reservoir 45, implantable device 20may close off fluidic communication to catheter 25 by appropriatelyactuating valve 49′, may open fluidic communication between catheters46′ and 23 by appropriately actuating valve 49, and may turn in a firstdirection so as to pump fluid from reservoir 45 via catheters 46′ and23. Reservoir 45 may alternatively be implanted inside the patient'sbody and connected to the exterior environment using a catheter topermit reservoir 45 to be refilled.

After the DSR infusate has dwelled in the peritoneal cavity for apredetermined amount of time, implantable device 20 may pump that DSRinfusate and the osmotic ultrafiltrate to the patient's bladder 13 byclosing off communication to catheter 46′ by appropriately actuatingvalve 49 and opening communication to catheter 25 by appropriatelyactuating valve 49′ and turning in a second direction (opposite from thefirst) so as to pump the fluid into bladder 13 via catheters 23 and 25.It should be appreciated that the functionalities of valves 49 and 49′may be provided by any desired number of valves that are disposedappropriately along catheters 23, 25, and 46′ and are controllablyactuated by implantable device 20, e.g., via valve controller 86illustrated in FIG. 4. In certain configurations, the use of one or morepassive valves (not controlled by implantable device 20) may beappropriate, e.g., valve 49′ may be a passive check valve disposed alongcatheter 25 that inhibits fluid to flow from the bladder to device 20.

Methods of using the exemplary implantable systems, such as illustratedin FIGS. 1A-1C, is now described with reference to FIG. 1D. Method 1000includes introducing no or low sodium DSR infusate to the peritonealcavity from a reservoir that is internal or external to the patient'sbody (step 1010). For example, as described above with reference to FIG.1B, the DSR infusate may be introduced using an external pump orgravity. Or, as described above with reference to FIG. 1C, the DSRinfusate may be introduced using implantable device 20 and one or morevalves in communication therewith. A sufficient amount of DSR infusateis introduced into the peritoneal cavity of the patient and allowed todwell, to remove sodium from the patient's body into the peritonealcavity and to cause the osmotic ultrafiltrate to accumulate in theperitoneal cavity, from where it is removed to the bladder.

Sodium is moved from the patient's body via the peritoneal membrane intothe peritoneal cavity, from where it is removed to the bladder. Thisreduces the level of sodium in the body resulting in the elimination offluid by i) the functioning kidneys through urination and ii) removal tothe bladder of the osmotic ultrafiltrate that accumulates in theperitoneal cavity, restoring the serum sodium concentration and reducingthe patient's volume of fluid (step 1020). The sodium-laden DSR infusateand osmotic ultrafiltrate is pumped from the peritoneal cavity to thebladder with the implantable device (step 1030). Such pumping may occurafter the DSR infusate has been in the peritoneal cavity for asufficient amount of time to draw a sufficient amount of sodium out ofthe body to alleviate the fluid overload as described above. Kidneys ofthe patient also may then excrete fluid through urination, therebyrestoring serum sodium concentration (step 1040).

Energy may be wirelessly transferred to the implantable device, and datareceived from the device, using a charging and communication system suchas described above with reference to FIG. 1A (step 1050). For example,the implantable device may record parameters reflective of the health ofthe patient and the operation of the device, which parameters may becommunicated to the charging and communication system. The data, e.g.,parameters recorded by the implantable device, then is provided tomonitoring and control software, which is in communication with thecharging and communication system and is under the control of thetreating physician (step 1060). Based on those parameters, the health ofthe patient may be assessed using the software, and the physician mayremotely communicate any modifications to the flow rate, volume, timeduration, or frequency with which the implantable device is to deliverthe DSR infusate to the peritoneal cavity before removing the DSRinfusate and the osmotic ultrafiltrate, containing the extracted sodium,to the bladder (step 1070). Such communication may be performed via thecharging and communication system.

Further details of selected components of the exemplary system of FIGS.1A-1C to practice the inventive methods are now provided with referenceto FIGS. 2A-8.

Peritoneal and Bladder Catheters

Referring to FIGS. 2A and 2B, peritoneal catheter 50 may be MedionicsInternational Inc.'s peritoneal dialysis Catheter, Model No. PSNA-100 ora catheter having similar structure and functionality. Peritonealcatheter 50 corresponds to peritoneal catheter 23 of FIGS. 1A-1C, andmay comprise tube 51 of medical-grade silicone including inlet (distal)end 52 having a plurality of through-wall holes 53 and outlet (proximal)end 54. Holes 53 may be arranged circumferentially offset by about 90degrees, as shown in FIG. 2B. Peritoneal catheter 50 may also include apolyester cuff (not shown) in the region away from holes 53, to promoteadhesion of the catheter to the surrounding tissue, thereby anchoring itin place. Alternatively, inlet end 52 of peritoneal catheter 50 may havea spiral configuration, and an atraumatic tip, with holes 53 distributedover a length of the tubing to reduce the risk of clogging.

Inlet end 52 also may include a polyester cuff to promote adhesion ofthe catheter to an adjacent tissue wall, thereby ensuring that the inletend of the catheter remains in position. Outlet end 54 also may includea connector for securing the outlet end of the peritoneal catheter toimplantable device 20. In one preferred embodiment, the distal end ofthe peritoneal catheter, up to the ingrowth cuff, may be configured topass through a conventional 16F peel-away sheath. In addition, thelength of the peritoneal catheter may be selected to ensure that it liesalong the bottom of the body cavity, and is sufficiently resistant totorsional motion so as not to become twisted or kinked during or afterimplantation.

With respect to FIG. 3A, a first embodiment of bladder catheter 60 isdescribed, corresponding to bladder catheter 25 of FIGS. 1A-1C. Bladdercatheter 60 preferably comprises tube 61 of medical-grade siliconehaving inlet (proximal) end 62 and outlet (distal) end 63 includingspiral structure 64, and polyester ingrowth cuff 65. Bladder catheter 60includes a single internal lumen that extends from inlet end 62 to asingle outlet at the tip of spiral structure 64, commonly referred to asa “pigtail” design. Inlet end 62 may include a connector for securingthe inlet end of the bladder catheter to implantable device 20, or mayhave a length that can be trimmed to fit a particular patient. In oneembodiment, bladder catheter 60 may have length L3 of about 45 cm, withcuff 65 placed length L4 of about 5 to 6 cm from spiral structure 64.Bladder catheter 60 may be loaded onto a stylet with spiral structure 64straightened, and implanted using a minimally invasive technique inwhich outlet end 63 and spiral structure 64 are passed through the wallof a patient's bladder using the stylet. When the stylet is removed,spiral structure 64 returns to the coiled shape shown in FIG. 3A. Onceoutlet end 63 of bladder catheter 60 is disposed within the patient'sbladder, the remainder of the catheter is implanted using a tunnelingtechnique, such that inlet end 62 of the catheter may be coupled toimplantable device 20. Spiral structure 64 may reduce the risk thatoutlet end 63 accidentally will be pulled out of the bladder before thetissue surrounding the bladder heals sufficiently to incorporateingrowth cuff 65, thereby anchoring the bladder catheter in place.

In a preferred embodiment, bladder catheter 60 is configured to passthrough a conventional peel-away sheath. Bladder catheter 60 preferablyis sufficiently resistant to torsional motion so as not to becometwisted or kinked during or after implantation. In a preferredembodiment, peritoneal catheter 50 and bladder catheter 60 preferablyare different colors, have different exterior shapes (e.g., square andround) or have different connection characteristics so that they cannotbe inadvertently interchanged during connection to implantable device20. Optionally, bladder catheter 60 may include an internal duckbillvalve positioned midway between inlet 62 and outlet end 63 of thecatheter to ensure that urine does not flow from the bladder into theperitoneal cavity if the bladder catheter is accidentally pulled freefrom the pump connector of implantable device 20 and/or if the pump ofimplantable device 20 is actuated so as to draw the DSR infusate fromreservoir 45 into the patient's peritoneal cavity.

In an alternative embodiment, the peritoneal and bladder cathetersdevices may incorporate one or several anti-infective agents to inhibitthe spread of infection between body cavities. Examples ofanti-infective agents which may be utilized may include, e.g.,bacteriostatic materials, bactericidal materials, one or more antibioticdispensers, antibiotic eluting materials, and coatings that preventbacterial adhesion, and combinations thereof. Additionally, implantabledevice 20 may include a UV lamp configured to irradiate fluid in theperitoneal and/or bladder catheters so as to kill any pathogens that maybe present and thus inhibit the development of infection, as describedfurther below with respect to FIGS. 4 and 5B.

Alternatively, rather than comprising separate catheters, peritoneal andbladder catheters 50, 60 may share a common wall, which may beconvenient because the bladder and peritoneal cavity share a commonwall, thereby facilitating insertion of a single dual-lumen tube. Inaddition, either or both of the peritoneal or bladder catheters may bereinforced along a portion of its length or along its entire lengthusing ribbon or wire braiding or lengths of wire or ribbon embedded orintegrated within or along the catheters. The braiding or wire may befabricated from metals such as stainless steels, superelastic metalssuch as nitinol, or from a variety of suitable polymers. Suchreinforcement may also be used for catheter 46 connected to optionalreservoir 45.

With respect to FIG. 3B, a second embodiment of a bladder catheter isdescribed, in which similar components are identified with like-primednumbers. Bladder catheter 60′ preferably comprises tube 61′ ofmedical-grade silicone having inlet end 62′, outlet end 63′ andpolyester ingrowth cuff 65′. In accordance with this embodiment, outletend 63′ includes malecot structure 66, illustratively comprising fourresilient wings 67 that expand laterally away from the axis of thecatheter to reduce the risk that outlet end 63′ of the catheter will beinadvertently pulled loose after placement. Inlet end 62′ may include aconnector for securing the inlet end of the bladder catheter toimplantable device 20, or may have a length that can be trimmed to fit aparticular patient.

Malecot structure 66 preferably is constructed so that wings 67 deformto a substantially flattened configuration when a stylet is insertedthrough the lumen of the catheter. In this manner, bladder catheter 60′may be loaded onto a stylet, and using a minimally invasive technique,outlet end 63′ and malecot structure 66 may be passed through the wallof a patient's bladder using the stylet. When the stylet is removed,wings 67 of the malecot structure return to the expanded shape shown inFIG. 3B. Once outlet end 63′ of bladder catheter 60′ is coupled to thepatient's bladder, the remainder of the catheter is implanted using atunneling technique, such that inlet end 62′ of the catheter may becoupled to implantable device 20. Malecot structure 66 may reduce therisk that outlet end 63′ accidentally will be pulled out of the bladderbefore the tissue surrounding the bladder heals sufficiently toincorporate ingrowth cuff 65′. As for the embodiment of FIG. 3A, thebladder catheter of FIG. 3B may be configured to pass through aconventional peel-away sheath, and preferably is sufficiently resistantto torsional motion so as not to become twisted or kinked during orafter implantation.

The Implantable Device

Referring now to FIG. 4, a schematic depicting the functional blocks ofimplantable device 20 suitable for use in practicing the methods of thepresent invention is described. Implantable device 20 includes controlcircuitry, illustratively processor 70 coupled to nonvolatile memory 71,such as flash memory or electrically erasable programmable read onlymemory, and volatile memory 72 via data buses. Processor 70 iselectrically coupled to electric motor 73, battery 74, inductive circuit75, radio transceiver 76, UV lamp 85, and a plurality of sensors,including humidity sensor 77, a plurality of temperature sensors 78,accelerometer 79, a plurality of pressure sensors 80, and respiratoryrate sensor 81. Inductive circuit 75 is electrically coupled to coil 84to receive energy transmitted from charging and communication system 30,while transceiver 76 is coupled to antenna 82, and likewise isconfigured to communicate with a transceiver in charging andcommunication system 30, as described below. Optionally, inductivecircuit 75 also may be coupled to infrared light emitting diode 83.Motor 73 may include a dedicated controller, which interprets andactuates motor 73 responsive to commands from processor 70. Optionally,processor 70 is further in communication with valve controller 86. Allof the components depicted in FIG. 4 are contained within a low volumesealed biocompatible housing, as shown in FIG. 5A.

Processor 70 executes firmware stored in nonvolatile memory 71 whichcontrols operation of motor 73 responsive to signals generated by motor73, sensors 77-81 and commands received from transceiver 76. Processor70 also controls reception and transmission of messages via transceiver76 and operation of inductive circuit 75 to charge battery 74. Inaddition, processor 70 receives signals generated by Hall Effect sensorslocated within motor 73, which are used to compute direction andrevolutions of the gears of the gear pump, and thus fluid volume pumpedand the viscosity of that fluid, as described below. Processor 70preferably includes a low-power mode of operation and includes aninternal clock, such that the processor can be periodically awakened tohandle pumping, pump tick mode, or communications and chargingfunctions, and/or awakened to handle commands received by transceiver 76from handpiece 32. In one embodiment, processor 70 comprises a member ofthe MSP430 family of microcontroller units available from TexasInstruments, Incorporated, Dallas, Tex., and may incorporate thenonvolatile memory, volatile memory, and radio transceiver componentsdepicted in FIG. 4. In addition, the firmware executed on processor 70may be configured to respond directly to commands sent to implantabledevice 20 via charging and communication system 30. Processor 70 also isconfigured to monitor operation of motor 72 (and any associated motorcontroller) and sensors 77-81, as described below, and to store datareflecting operation of the implantable device, including event logs andalarms. Thus, data is reported to the charging and communication systemwhen it is next wirelessly coupled to the implantable device. In apreferred embodiment, processor 70 generates up to eighty log entriesper second prior to activating the pump, about eight log entries persecond when the implantable system is actively pumping and about one logentry per hour when not pumping.

Nonvolatile memory 71 preferably comprises flash memory or EEPROM, andstores a unique device identifier for implantable device 20, firmware tobe executed on processor 70, configuration set point data relating tooperation of the implantable device, and optionally, coding to beexecuted on transceiver 76 and/or inductive circuit 75, and a separatemotor controller, if present. Firmware and set point data stored onnonvolatile memory 71 may be updated using new instructions provided bycontrol and monitoring system 40 via charging and communication system30. Volatile memory 72 is coupled to and supports operation of processor70, and stores data and event log information gathered during operationof implantable device 20. Volatile memory 72 also serves as a buffer forcommunications sent to, and received from, charging and communicationsystem 30.

Transceiver 76 preferably comprises a radio frequency transceiver and isconfigured for bi-directional communications via antenna 76 with asimilar transceiver circuit disposed in handpiece 32 of charging andcommunication system 30. Transceiver 76 also may include a low powermode of operation, such that it periodically awakens to listen forincoming messages and responds only to those messages including theunique device identifier assigned to that implantable device.Alternatively, because transceiver 76 communicates only with thecorresponding transceiver in handpiece 32 of its associated charging andcommunication system 30, transceiver 76 may be configured to send orreceive data only when inductive circuit 75 of the implantable device isactive. In addition, transceiver 76 may employ an encryption routine toensure that messages sent from, or received by, the implantable devicecannot be intercepted or forged.

Inductive circuit 75 is coupled to coil 84, and is configured torecharge battery 74 of the implantable device when exposed to a magneticfield supplied by a corresponding inductive circuit within handpiece 32of charging and communication system 30. In one embodiment, inductivecircuit 75 is coupled to optional infrared LED 83 that emits an infraredsignal when inductive circuit 75 is active. The infrared signal may bereceived by handpiece 32 of charging and communication system 30 toassist in locating the handpiece relative to the implantable device,thereby improving the magnetic coupling and energy transmission to theimplantable device.

Inductive circuit 75 optionally may be configured not only to rechargebattery 74, but to directly provide energy to motor 73 in a “boost” modeor jog/shake mode to unblock the pump. In particular, if processor 70detects that motor 73 is stalled, e.g., due to a block created by fibrinor other debris in the peritoneal cavity, an alarm may be stored inmemory. When implantable device 20 next communicates with charging andcommunication system 30, the alarm is reported to handpiece 32, and thepatient may be given the option of depressing multifunction button 34 toapply an overvoltage to motor 73 from inductive circuit 75 for apredetermined time period to free the pump blockage. Alternatively,depressing the multi-function button may cause processor 70 to execute aset of commands by which motor 73 is jogged or shaken, e.g., byalternatingly running the motor is reverse and then forward, to disruptthe blockage. Because such modes of operation may employ higher energyconsumption than expected during normal operation, it is advantageous todrive the motor during such procedures with energy supplied viainductive circuit 75.

Battery 74 preferably comprises a lithium ion or lithium polymer batterycapable of long lasting operation, e.g., up to three years, whenimplanted in a human, so as to minimize the need for re-operations toreplace implantable device 20. In one preferred embodiment, battery 74supplies a nominal voltage of 3.6V, a capacity of 150 mAh when new, anda capacity of about 120 mAh after two years of use. Preferably, battery74 is configured to supply a current of 280 mA to motor 73 when pumping;25 mA when the transceiver is communicating with charging andcommunication system 30; 8 mA when processor 70 and related circuitry isactive, but not pumping or communicating; and 0.3 mA when theimplantable device is in low power mode. More preferably, battery 74should be sized to permit a minimum current of at least 450 mAh for aperiod of 10 seconds and 1 A for 25 milliseconds during each chargingcycle.

Motor 73 preferably is a brushless direct current or electronicallycommuted motor having a splined output shaft that drives a set offloating gears that operate as a gear pump, as described below. Motor 73may include a dedicated motor controller, separate from processor 70,for controlling operation of the motor. Motor 73 may include a pluralityof Hall Effect sensors, preferably two or more, for determining motorposition and direction of rotation. Due to the high humidity that may beencountered in implantable device 20, processor 70 may includeprogramming to operate motor 73, although with reduced accuracy, even ifsome or all of the Hall Effect sensors fail.

In a preferred embodiment, motor 73 is capable of driving the gear pumpto generate a nominal flow rate of 150 ml/min and applying a torque ofabout 1 mNm against a pressure head of 30 cm water at 3000 RPM. In thisembodiment, the motor preferably is selected to drive the gears at from1000 to 5000 RPM, corresponding to flow rates of from 50 to 260 ml/min,respectively. The motor preferably has a stall torque of at least 3 mNmat 500 mA at 3 V, and more preferably 6 mNm in order to crush non-solidproteinaceous materials. As discussed above, the motor preferably alsosupports a boost mode of operation, e.g., at 5 V, when powered directlythrough inductive circuit 75. Motor 73 preferably also is capable ofbeing driven in reverse as part of a jogging or shaking procedure tounblock the gear pump.

Processor 70 may be programmed to automatically and periodically wake upand enter a pump tick mode. In this mode of operation, the gear pump isadvanced slightly, e.g., about 120 degrees as measured by the HallEffect sensors, before processor 70 returns to low power mode.Preferably, this interval is about every 20 minutes, although it may beadjusted by the physician using the monitoring and control system. Thispump tick mode is expected to prevent the DSR infusate and the osmoticultrafiltrate from partially solidifying, and blocking the gear pump.

In addition, processor 70 also may be programmed to enter a jog or shakemode when operating on battery power alone, to unblock the gear pump.Similar to the boost mode available when charging the implantable devicewith the handpiece of charging and communication system 30, the jog orshake mode causes the motor to rapidly alternate the gears betweenforward and reverse directions to crush or loosen any buildup of tissueor other debris in the gear pump or elsewhere in the fluid path.Specifically, in this mode of operation, if the motor does not start toturn within a certain time period after it is energized (e.g., 1second), the direction of the motion is reversed for a short period oftime and then reversed again to let the motor turn in the desireddirection. If the motor does still not turn (e.g., because the gear pumpis jammed) the direction is again reversed for a period of time (e.g.,another 10 msec). If the motor still is not able to advance the timeinterval between reversals of the motor direction is reduced to allowfor the motor to develop more power, resulting in a shaking motion ofthe gears. If the motor does not turn forward for more than 4 seconds,the jog mode of operation is stopped, and an alarm is written to theevent log. If the motor was unable to turn forward, processor 70 willintroduce a backwards tick before the next scheduled fluid movement. Abackward tick is the same as a tick (e.g., about 120 degrees forwardmovement of the motor shaft) but in the reverse direction, and isintended to force the motor backwards before turning forward, whichshould allow the motor to gain momentum.

Sensors 77-81 continually monitor humidity, temperature, acceleration,pressure, and respiratory rate, and provide corresponding signals toprocessor 70 which stores the corresponding data in memory 71 for latertransmission to monitoring and control system 40. In particular,humidity sensor 77 is arranged to measure humidity within the housing ofthe implantable device, to ensure that the components of implantabledevice are operated within expected operational limits. Humidity sensor77 preferably is capable of sensing and reporting humidity within arange or 20% to 100% with high accuracy. One or more of temperaturesensors 78 may be disposed within the housing and monitor thetemperature of the implantable device, and in particular battery 74 toensure that the battery does not overheat during charging, while anotherone or more of temperature sensors 78 may be disposed so as to contactfluid entering at inlet 62 and thus monitor the temperature of thefluid, e.g., for use in assessing the patient's health. Accelerometer 79is arranged to measure acceleration of the implant, preferably along atleast two axes, to detect periods of activity and inactivity, e.g., todetermine whether the patient is sleeping or to determine whether andwhen the patient is active. This information is provided to processor 70to ensure that the pump is not operated when the patient is indisposedto attend to voiding of the bladder.

Implantable device 20 preferably includes multiple pressure sensors 80,which are continually monitored during waking periods of the processor.As described below with respect to FIG. 6A, the implantable device ofthe present invention preferably includes four pressure sensors: asensor to measure the pressure in the peritoneal cavity, a sensor tomeasure the ambient pressure, a sensor to measure the pressure at theoutlet of the gear pump, and a sensor to measure the pressure in thebladder. These sensors preferably are configured to measure absolutepressure between 450 mBar and 1300 mBar while consuming less than 50 mWat 3V. Preferably, the sensors that measure pressure at the pump outletand in the bladder are placed across a duckbill valve, which preventsreverse flow of urine and/or used DSR infusate and/or osmoticultrafiltrate back into the gear pump and also permits computation offlow rate based on the pressure drop across the duckbill valve.

Respiratory rate monitor 81 is configured to measure the patient'srespiratory rate, e.g., for use in assessing the patient's health.Alternatively, the patient's respiratory rate may be measured based onthe outputs of one or more of pressure sensors 80, e.g., based onchanges in the ambient pressure or the pressure in the peritoneal cavitycaused by the diaphragm periodically compressing that cavity duringbreathing.

Any desired number of additional sensors for measuring the health of thepatient may also be provided in operable communication with processor 70and may output recordable parameters for storage in memory 71 andtransmission to monitoring and control system 40, that the physician mayuse to assess the patient's health. For example, chemical or biochemicalsensors may be provided that are configured to monitor the compositionand/or sodium concentration of the sodium-laden DSR infusate and osmoticultrafiltrate.

Processor 70 preferably is programmed to pump a predetermined volume offluid from the peritoneal cavity to the bladder after that fluid hasbeen in the peritoneal cavity for a predetermined amount of time andwith a predetermined frequency. Such volume, time, and frequencypreferably are selected to optimize sodium removal to maintain orimprove the patient's health and to alleviate the fluid overload. Thevolume, time, and frequency may be selected based on the patient'ssymptoms, the activity and habits of the patient, the permeability ofthe peritoneal membrane and the osmotic characteristics of the DSRinfusate. For example, the physician may initially program processor 70with a first time, volume, and frequency based on his perception of thepatient's health and habits, and later may adjust that initialprogramming to vary the volume, time, and/or frequency based on hisperception of changes in the patient's health, for example based onchanges over time in parameters measured by implantable device 20 andrelayed to the physician via monitoring and control software 40.

Processor 70 also may be programmed to monitor the sensors 77-81 and togenerate an alert condition that is relayed to the clinician indicativeof a potential decline in the patient's health. For example, processor70 may monitor pressure sensors 80 to determine whether, overpredetermined time intervals, there is an increase in pressure withinthe peritoneal cavity. Such pressure increases may be the result of anincrease in the rate of accumulation of fluid in the peritoneal cavity,which may in turn indicate heart failure decompensation. Such an alertmay result in the patient being directed to seek immediate treatment andarrest such decompensation.

In other embodiments, processor 70 may be programmed to pump fluid fromthe peritoneal cavity to the bladder only when the pressure in theperitoneal cavity exceeds a first predetermined value, and the pressurein the bladder is less than a second predetermined value, so that thebladder does not become overfull. To account for patient travel from alocation at sea level to a higher altitude, the ambient pressuremeasurement may be used to calculate a differential value for theperitoneal pressure. In this way, the predetermined pressure at whichthe pump begins operation may be reduced, to account for loweratmospheric pressure. Likewise, the ambient pressure may be used toadjust the predetermined value for bladder pressure. In this way, thethreshold pressure at which the pumping ceases may be reduced, becausethe patient may experience bladder discomfort at a lower pressure whenat a high altitude location.

Further, processor 70 may be programmed to include a timer that monitorsthe elapsed time from when the DSR infusate was pumped from thereservoir to the patient's peritoneal cavity, and after expiration of apredetermined or patient-settable dwell time, to pump the sodium-ladenDSR infusate and osmotic ultrafiltrate from the peritoneal cavity to thepatient's bladder. Such timer programming also may include an overridefeature, such that a parameter measured by sensors 77-81, such as excesspressure in the peritoneal cavity, may trigger transfer of the contentsof the peritoneal cavity to the bladder prior to expiration of adesignated dwell time.

Optionally, controller 70 is in operable communication with UV lamp 85,which is configured to irradiate and thus kill pathogens in the DSRinfusate both before and after fluid is provided to or extracted fromthe peritoneal cavity. UV lamp 85 preferably generates light in the UV-Cspectral range (about 200-280 nm), particularly in the range of about250-265 nm, which is also referred to as the “germicidal spectrum”because light in that spectral range breaks down nucleic acids in theDNA of microorganisms. Low-pressure mercury lamps have an emission peakat approximately 253.7 nm, and may suitably be used for UV lamp 85.Alternatively, UV lamp 85 may be a UV light emitting diode (LED), whichmay be based on AlGaAs or GaN.

Under the control of controller 70, UV lamp 85 irradiates any fluidpassing through the implantable device for a preselected amount of timesufficient to kill pathogens that may be present in that fluid.Specifically, the flow rate of the fluid through the device may beselected (e.g., pre-programmed) so as to irradiate the fluid with asufficient dosage of UV light to inhibit the growth of colonies ofpathogens. For example, it is known that dosages of 253.7 nm UV light ofbetween about 5,500-7,000 μWs/cm² are sufficient to provide 100% killrates for many organisms, including E. coli, Proteus spp., Klebsiellaspp., Serratia spp., Leptospirosis spp., Staphylococcus haemolyticus,and Enterococci. Higher dosages, e.g., between about 8,500-12,000μWs/cm², may be required to provide 100% kill rates for other organisms,including Kliebsiella ssp., Enterobacter spp., Psuedomonas spp., andNeisseria gonorrhoeae. However, the dosage to sufficiently inhibitcolony growth may be lower. For example, E. coli requires only 3000μWs/cm² to inhibit growth, whereas 6,600 μWs/cm² may be needed toprovide a 100% kill rate. Controller 70 may be pre-programmed to set aflow rate of fluid through the tubing sufficient to inhibit colonygrowth of one or more target pathogens based on the intensity of UV lamp85, the reflective conditions within the portion of the housing in whichUV lamp 85 is used (e.g., upper portion 93 described below withreference to FIG. 5B), the configuration of the tubing being exposed tothe UV lamp, the distance between the tubing and the UV lamp, and thesusceptibility of target pathogens to the spectrum emitted by UV lamp85.

Still referring to FIG. 4, in some embodiments processor 70 also may bein communication with valve controller 86; alternatively, valvecontroller 86 may be part of the functionality of processor 70. Valvecontroller 86 controls the actuation of any valves that may be used tocontrol the flow of DSR infusate between the reservoir, the peritonealcavity, and the bladder. For example, as described above with referenceto FIG. 1C, implantable device 20 may be configured to pump the DSRinfusate from an external or internal reservoir to the peritonealcavity, while actuating valves 49 and 49′ so as to close fluidic accessto the bladder and thus avoid inadvertently pumping fluid from thebladder into the peritoneal cavity; and may be configured to pump fluidfrom the peritoneal cavity to the bladder, while actuating valves 49 and49′ so as to close fluidic access to the reservoir and thus avoidinadvertently pumping fluid from the peritoneal cavity into thereservoir. Valve controller 86 may coordinate the actuation of valves 49and 49′ in such a manner, or in any other appropriate manner based onthe particular valve configuration.

Referring now to FIGS. 5A and 5B, further details of an exemplaryembodiment of implantable device 90 are provided. In FIG. 5A, housing 91is shown as transparent, although it should of course be understood thathousing 91 comprises an opaque biocompatible plastic, glass and/or metalalloy materials. In FIG. 5B, the implantable device is shown with lowerportion 92 of housing 91 removed from upper housing 93 and without aglass bead/epoxy filler material that is used to prevent moisture fromaccumulating in the device. In FIGS. 5A and 5B, motor 94 is coupled togear pump housing 95, which is described in greater detail with respectto FIG. 6. The electronic components discussed above with respect toFIG. 4 are disposed on circuit board substrate 96, which extends aroundand is fastened to support member 97. Coil 98 (corresponding to coil 84of FIG. 4) is disposed on flap 99 of the substrate and is coupled to theelectronic components on flap 100 by flexible cable portion 101. Supportmember 97 is fastened to upper housing 93 and provides a cavity thatholds battery 102 (corresponding to battery 74 of FIG. 4). Lower portion92 of housing 91 includes port 103 for injecting the glass bead/epoxymixture after upper portion 93 and lower portion 92 of housing 91 arefastened together, to reduce space in the housing in which moisture canaccumulate.

Housing 91 also may include features designed to reduce movement of theimplantable pump once implanted within a patient, such as a suture holeto securely anchor the implantable device to the surrounding tissue.Housing 91 may in addition include a polyester ingrowth patch thatfacilitates attachment of the implantable device to the surroundingtissue following subcutaneous implantation.

Additionally, the implantable device optionally may incorporateanti-clogging agents, such enzyme eluting materials that specificallytarget the proteinaceous components of fluid from the peritoneal cavity,enzyme eluting materials that specifically target the proteinaceous andencrustation promoting components of urine, chemical eluting surfaces,coatings that prevent adhesion of proteinaceous compounds, andcombinations thereof. Such agents, if provided, may be integrated withinor coated upon the surfaces of the various components of the system.

Referring to FIG. 5B, upper housing 93 optionally includes UV lamp 85.Within upper housing 93, the fluid channels 88 for conducting the fluidmay extend approximately linearly, or alternatively may include one ormore curves or bends so as to increase the volume of fluid that may besimultaneously exposed UV lamp 86, and thus allow for an increase in theflow rate. For example, the fluid channels 88 may include an approximatespiral, an approximate sine wave, or an approximate “S” curve so as toincrease the volume of fluid that may be simultaneously exposed to UVlamp 86. Upper housing 93 further may include reflective coating 87,e.g., a white coating such as ZnO or other diffuse or Lambertianreflector, so as to enhance irradiation of the tubing and shield thepatient from potential UV light exposure.

Referring now to FIGS. 6A to 6D, further details of the gear pump andfluid path are described. In FIGS. 6A-6D, like components are identifiedusing the same reference numbers from FIGS. 5A and 5B. FIG. 6A is anexploded view showing assembly of motor 94 with gear pump housing 95 andupper housing 93, as well as the components of the fluid path within theimplantable device. Upper housing 93 preferably comprises a highstrength plastic or metal alloy material that can be molded or machinedto include openings and channels to accommodate inlet nipple 102, outletnipple 103, pressure sensors 104 a-104 d, manifold 105 and screws 106.Nipples 102 and 103 preferably are machined from a high strengthbiocompatible metal alloy, and outlet nipple 103 further includeschannel 107 that accepts elastomeric duckbill valve 108. Outlet nipple103 further includes lateral recess 109 that accepts pressure sensor 104a, which is arranged to measure pressure at the inlet end of the bladdercatheter, corresponding to pressure in the patient's bladder (orperitoneal cavity).

Referring now also to FIGS. 6B and 6C, inlet nipple 102 is disposedwithin opening 110, which forms a channel in upper housing 93 thatincludes opening 111 for pressure sensor 104 b and opening 112 thatcouples to manifold 105. Pressure sensor 104 b is arranged to measurethe pressure at the outlet end of the peritoneal catheter, correspondingto pressure in the peritoneal cavity. Outlet nipple 103, includingduckbill valve 107, is disposed within opening 113 of upper housing 93so that lateral recess 108 is aligned with opening 114 to permit accessto the electrical contacts of pressure sensor 104 a. Opening 113 formschannel 115 that includes opening 116 for pressure sensor 104 c, andopening 117 that couples to manifold 105. Upper housing 93 preferablyfurther includes opening 118 that forms a channel including opening 119for accepting pressure sensor 104 d. Pressure sensor 104 d measuresambient pressure, and the output of this sensor is used to calculatedifferential pressures as described above. Upper housing furtherincludes notch 120 for accepting connector 26 (see FIG. 1A) forretaining the peritoneal and bladder catheters coupled to inlet andoutlet nipples 102 and 103. Upper housing 93 further includes recess 121to accept manifold 105, and peg 122, to which support member 97 (seeFIG. 5B) is connected.

Manifold 105 preferably comprises a molded elastomeric component havingtwo separate fluid channels (such channels designated 88 in FIG. 5B)that couple inlet and outlet flow paths through upper housing 93 to thegear pump. The first channel includes inlet 124 and outlet 125, whilethe second channel includes inlet 126 and outlet 127. Inlet 124 couplesto opening 112 (see FIG. 6C) of the peritoneal path and outlet 127couples to opening 117 of the bladder path. Manifold 105 is configuredto improve manufacturability of the implantable device, by simplifyingconstruction of upper housing 93 and obviating the need to either castor machine components with complicated non-linear flow paths. OptionalUV lamp 86 and surface 87 (not shown in FIGS. 6A-6D) may be placed insuitable positions within housing 93 and relative to manifold 105 tosufficiently irradiate the fluid as motor 94 pumps the fluid throughhousing 93.

Motor 94 is coupled to gear pump housing 95 using mating threads 130,such that splined shaft 131 of motor 94 passes through bearing 132. Thegear pump of the present invention comprises intermeshing gears 133 and134 enclosed in gear pump housing 95 by O-ring seal 135 and plate 136.The gear pump is self-priming. Plate 136 includes openings 137 and 138that mate with outlet 125 and inlet 126 of manifold 105, respectively.Splined shaft 131 of motor 94 extends into opening 139 of gear 133 toprovide floating engagement with that gear.

The Charging and Communication System

Referring to FIGS. 7A, 7B and 8, charging and communication system 150(corresponding to system 30 of FIG. 1A) is described in greater detail.In one preferred embodiment, charging and communication system 150comprises handpiece 151 and base 31 (see FIG. 1A). Base 31 providescomprises a cradle for recharging handpiece 151, and preferably containsa transformer and circuitry for converting conventional 120/220/240Vpower service to a suitable DC current to charge handpiece 151 when itis coupled to the base. Alternatively, handpiece 151 may includecircuitry for charging the handpiece battery, and a detachable powercord. In this embodiment, handpiece 151 may be directly plugged into awall socket for charging, and the power cord removed when the handpieceis used to recharge the implantable device.

As shown in FIG. 8, handpiece 151 contains controller 152,illustratively the processor of a micro-controller unit coupled tononvolatile memory 153 (e.g., either EEPROM or flash memory), volatilememory 154, radio transceiver 155, inductive circuit 156, battery 157,indicator 158 and display 159. Controller 152, memories 153 and 154, andradio transceiver 155 may be incorporated into a single microcontrollerunit, such as the MPS430 family of microprocessors, available from TexasInstruments Incorporated, Dallas, Tex. Transceiver 155 is coupled toantenna 160 for sending and receiving information to implantable device20. Battery 157 is coupled to connector 161 that removably couples witha connector in base 31 to recharge the battery. Port 162, such as a USBport or comparable wireless circuit, is coupled to controller 152 topermit information to be exchanged between handpiece 151 and themonitoring and control system. Inductive circuit 156 is coupled to coil163. Input device 164, preferably a multi-function button, also iscoupled to controller 152 to enable a patient to input a limited numberof commands. Indicator 158 illustratively comprises a plurality of LEDsthat illuminate to indicate the quality of charge coupling achievedbetween the handpiece and implantable device, and therefore assist inoptimizing the positioning of handpiece 151 relative to the implantabledevice during recharging. In one preferred embodiment, indicator 158 isomitted, and instead a bar indicator provided on display 159 thatindicates the quality-of-charging resulting from the coupling of coils163 and 84.

In a preferred embodiment, handpiece 151 includes a device identifierstored in nonvolatile memory 153 that corresponds to the deviceidentifier stored in nonvolatile memory 71 of the implantable device,such that handpiece 151 will communicate only with its correspondingimplantable device 20. Optionally, a configurable handpiece for use in aphysician's office may include the ability to interrogate an implantabledevice to request that device's unique device identifier, and thenchange the device identifier of the monitoring and control system 40 tothat of the patient's implantable device, so as to mimic the patient'shandpiece. In this way, a physician may adjust the configuration of theimplantable device if the patient forgets to bring his handpiece 151with him during a visit to the physician's office.

Controller 152 executes firmware stored in nonvolatile memory 153 thatcontrols communications and charging of the implantable device.Controller 152 also is configured to transfer and store data, such asevent logs, uploaded to handpiece 151 from the implantable device, forlater retransmission to monitoring and control system 40 via port 162,during physician office visits. Alternatively, handpiece 151 may beconfigured to recognize a designated wireless access point within thephysician's office, and to wirelessly communicate with monitoring andcontrol system 40 during office visits. As a further alternative, base31 may include telephone circuitry for automatically dialing anduploading information stored on handpiece 151 to a physician's websitevia a secure connection, such as alarm information.

Controller 152 preferably includes a low-power mode of operation andincludes an internal clock, such that the controller periodicallyawakens to communicate with the implantable device to log data or toperform charging functions. Controller 152 preferably is configured toawaken when placed in proximity to the implantable device to performcommunications and charging functions, and to transmit commands inputusing input device 164. Controller 152 further may include programmingfor evaluating information received from the implantable device, andgenerating an alarm message on display 159. Controller 152 also mayinclude firmware for transmitting commands input using input device 164to the implantable device, and monitoring operation of the implantabledevice during execution of such commands, for example, during boost orjogging/shaking operation of the gear pump to clear a blockage. Inaddition, controller 152 controls and monitors various power operationsof handpiece 151, including operation of inductive circuit 156 duringrecharging of the implantable device, displaying the state of charge ofbattery 74, and controlling charging and display of state of chargeinformation for battery 157.

Nonvolatile memory 153 preferably comprises flash memory or EEPROM, andstores the unique device identifier for its associated implantabledevice, firmware to be executed by controller 152, configuration setpoint, and optionally, coding to be executed on transceiver 155 and/orinductive circuit 156. Firmware and set point data stored on nonvolatilememory 153 may be updated using information supplied by control andmonitoring system 40 via port 162. Volatile memory 154 is coupled to andsupports operation of controller 152, and stores data and event loginformation uploaded from implantable device 20.

In addition, in a preferred embodiment, nonvolatile memory 153 storesprogramming that enables the charging and communication system toperform some initial start-up functions without communicating with themonitor and control system. In particular, memory 153 may includeroutines that make it possible to test the implantable device duringimplantation using the charging and communication system alone in a“self-prime mode” of operation. In this case, a button may be providedthat allows the physician to manually start the pump, and display 159 isused to provide feedback whether the pumping session was successful ornot. Display 159 of the charging and communication system also may beused to display error messages designed to assist the physician inadjusting the position of the implantable device or peritoneal orbladder catheters. These functions preferably are disabled after theinitial implantation of the implantable device.

Transceiver 155 preferably comprises a radio frequency transceiver,e.g., conforming to the Bluetooth or IEEE 802.11 wireless standards, andis configured for bi-directional communications via antenna 160 withtransceiver circuit 76 disposed in the implantable device. Transceiver155 also may include a low power mode of operation, such that itperiodically awakens to listen for incoming messages and responds onlyto those messages including the unique device identifier assigned to itsassociated implantable device. Transceiver 155 preferably employs anencryption routine to ensure that messages sent to, or received from,the implantable device cannot be intercepted or forged.

Inductive circuit 156 is coupled to coil 163, and is configured toinductively couple with coil 84 of the implantable device to rechargebattery 74 of the implantable device. In one embodiment, inductivecircuit 156 is coupled to indicator 158, preferably a plurality of LEDsthat light to indicate the extent of magnetic coupling between coils 163and 84 (and thus quality of charging), thereby assisting in positioninghandpiece 151 relative to the implantable device. In one preferredembodiment, inductive coils 84 and 163 are capable of establishing goodcoupling through a gap of 35 mm, when operating at a frequency of 315kHz or less. In an embodiment in which implantable device includesoptional infrared LED 83, charging and communication system 30 mayinclude an optional infrared sensor (not shown) which detects thatinfrared light emitted by LED 83 and further assists in positioninghandpiece 151 to optimize magnetic coupling between coils 163 and 84,thereby improving the energy transmission to the implantable device.

Controller 152 also may be configured to periodically communicate withthe implantable device to retrieve temperature data generated bytemperature sensor 78 and stored in memory 72 during inductive chargingof battery 74. Controller 152 may include firmware to analyze thebattery temperature, and to adjust the charging power supplied toinductive circuit 163 to maintain the temperature of the implantabledevice below a predetermined threshold, e.g., less than 2 degrees C.above body temperature. That threshold may be set to reduce thermalexpansion of the battery and surrounding electronic and mechanicalcomponents, for example, to reduce thermal expansion of motor and gearpump components and to reduce the thermal strain applied to the sealbetween lower portion 92 of housing and upper housing 93. In a preferredembodiment, power supplied to inductive coil 163 is cycled between highpower (e.g., 120 mA) and low power (e.g., 40 mA) charging intervalsresponsive to the measured temperature within the implantable device.

As discussed above with respect to inductive circuit 75 of theimplantable device, inductive circuit 156 optionally may be configuredto transfer additional power to motor 73 of the implantable device, viainductive circuit 75 and battery 74, in a “boost” mode or jogging modeto unblock the gear pump. In particular, if an alarm is transmitted tocontroller 152 that motor 73 is stalled, e.g., due to a block created byviscous fluid, the patient may be given the option of using input device164 to apply an overvoltage to motor 73 from inductive circuit 75 for apredetermined time period to free the blockage. Alternatively,activating input device 164 may cause controller 152 to commandprocessor 70 to execute a routine to jog or shake the gear pump byrapidly operating motor 74 in reverse and forward directions to disruptthe blockage. Because such modes of operation may employ higher energyconsumption than expected during normal operation, inductive circuits156 and 75 may be configured to supply the additional energy for suchmotor operation directly from the energy stored in battery 157, insteadof depleting battery 74 of the implantable device.

Battery 157 preferably comprises a lithium ion or lithium polymerbattery capable of long lasting operation, e.g., up to three years.Battery 157 has sufficient capacity to supply power to handpiece 151 tooperate controller 152, transceiver 155, inductive circuit 156 and theassociated electronics while disconnected from base 31 and duringcharging of the implantable device. In a preferred embodiment, battery157 has sufficient capacity to fully recharge battery 74 of theimplantable device from a depleted state in a period of about 2-4 hours.Battery 157 also should be capable of recharging within about 2-4 hours.It is expected that for daily operation moving 700 ml of fluid, battery157 and inductive circuit 156 should be able to transfer sufficientcharge to battery 74 via inductive circuit 75 to recharge the batterywithin about 30 minutes. Battery capacity preferably is supervised bycontroller 152 using a charge accumulator algorithm.

Referring again to FIGS. 7A and 7B, handpiece 151 preferably includeshousing 165 having multi-function button 166 (corresponding to inputdevice 164 of FIG. 8) and display 167 (corresponding to display 159 ofFIG. 8). A plurality of LEDs 168 is disposed beneath a translucentportion of handpiece 151, and corresponds to indicator 158 of FIG. 8.Port 169 enables the handpiece to be coupled to monitoring and controlsystem 40 (and corresponds to port 162 of FIG. 8), while connector 170(corresponding to connector 161 in FIG. 8) permits the handpiece to becoupled to base 31 to recharge battery 157. Multi-function button 166provides the patient the ability to input a limited number of commandsto the implantable device. Display 167, preferably an OLED or LCDdisplay, provides visible confirmation that a desired command inputusing multifunction button 166 has been received. Display 167 also maydisplay the status and state of charge of battery 74 of the implantabledevice, the status and state of charge of battery 157 of handpiece 151,signal strength of wireless communications, quality-of-charging, errorand maintenance messages. Inductive coil portion 171 of housing 165houses inductive coil 163.

LEDs 168 are visible through the material of housing 165 when lit, andpreferably are arranged in three rows of two LEDs each. During charging,the LEDs light up to display the degree of magnetic coupling betweeninductive coils 163 and 84, e.g., as determined by energy loss frominductive circuit 156, and may be used by the patient to accuratelyposition handpiece 151 relative to the implantable device. Thus, forexample, a low degree of coupling may correspond to lighting of only twoLEDs, an intermediate degree of coupling with lighting of four LEDs, anda preferred degree of coupling being reflected by lighting of all sixLEDs. Using this information, the patient may adjust the position ofhandpiece 151 over the area where implantable device is located toobtain a preferred position for the handpiece, resulting in the shortestrecharging time. In one preferred embodiment, LEDs 168 are replaced withan analog bar display on display 167, which indicates the quality ofcharge coupling.

The Monitoring and Control System

Turning to FIG. 9, the software implementing monitoring and controlsystem of FIG. 1A will now be described. Software 180 comprises a numberof functional blocks, schematically depicted in FIG. 9, including mainblock 184, event logging block 182, data download block 183,configuration setup block 184, user interface block 185, alarm detectionblock 186 including health monitor block 191 and infection predictionblock 192, sensor calibration block 187, firmware upgrade block 188,device identifier block 189 and status information block 190. In oneembodiment, the software is coded in C++ and employs an object orientedformat, although other software languages and environments could beused. In one embodiment, the software is configured to run on top of aMicrosoft Windows® (a registered trademark of Microsoft Corporation,Redmond, Wash.) or Unix-based operating system, such as areconventionally employed on desktop and laptop computers, although otheroperating systems could be employed.

The computer running monitoring and control system software 180preferably includes a data port, e.g., USB port or comparable wirelessconnection that permits handpiece 151 of the charging and communicationsystem to be coupled via port 169. Alternatively, as discussed above,the computer may include a wireless card, e.g., conforming to the IEEE802.11 standard, thereby enabling handpiece 151 to communicatewirelessly with the computer running software 180. As a furtheralternative, the charging and communication system may include telephonycircuitry that automatically dials and uploads data, such as alarm data,from handpiece 151 to a secure website accessible by the patient'sphysician.

Main block 184 preferably consists of a main software routine thatexecutes on the physician's computer, tablet or smartphone, and controlsoverall operation of the other functional blocks. Main block 184 enablesthe physician to download event data and alarm information stored onhandpiece 151 to their computer, tablet or smartphone, and also permitscontrol and monitoring software 180 to directly control operation of theimplantable device when coupled to handpiece 151. Main block alsoenables the physician to upload firmware updates and configuration datato the implantable device.

Event Log block 182 is a record of operational data downloaded from theimplantable device via the charging and communication system, and mayinclude, for example, pump start and stop times, motor position, sensordata for the peritoneal cavity and bladder pressures, patienttemperature, respiratory rate or fluid temperature, pump outletpressure, humidity, pump temperature, battery current, battery voltage,battery status, and the like. The event log also may include theoccurrence of events, such as pump blockage, operation in boost or jogmodes, alarms or other abnormal conditions.

Data Download block 183 is a routine that handles communication withhandpiece 151 to download data from volatile memory 154 after thehandpiece is coupled to the computer running monitoring and controlsoftware 180. Data Download block 183 may initiates, eitherautomatically or at the instigation of the physician via user interfaceblock 185, downloading of data stored in the event log.

Configuration Setup block 184 is a routine that configures theparameters stored within nonvolatile memory 71 that control operation ofthe implantable device. The interval timing parameters may determine,e.g., how long the processor remains in sleep mode prior to beingawakened to listen for radio communications or to control pumpoperation. The interval timing parameters may control, for example, theduration of pump operation to move fluid from the peritoneal cavity tothe bladder and the interval between periodic tick movements thatinhibit blockage of the implantable device and peritoneal and bladdercatheters. Interval timing settings transmitted to the implantabledevice from monitoring and control software 180 also may determine whenand how often event data is written to nonvolatile memory 71, and toconfigure timing parameters used by the firmware executed by processor152 of handpiece 151 of the charging and communication system. Block 184also may be used by the physician to configure parameters stored withinnonvolatile memory 71 relating to limit values on operation of processor70 and motor 73. These values may include minimum and maximum pressuresat the peritoneal and bladder catheters, the maximum temperaturedifferential during charging, times when the pump may and may notoperate, etc. The limit values set by block 184 also configureparameters that control operation of processor 152 of handpiece 151.

Block 184 also may configure parameters store within nonvolatile memory71 of the implantable device relating to control of operation ofprocessor 70 and motor 73. These values may include target daily volumesof fluid to transport, volume of fluid to be transported per pumpingsession, motor speed and duration per pumping session. Block 184 alsomay specify the parameters of operation of motor 73 during boost mode ofoperation, when coupled to handpiece 151, and shake/jog modes ofoperation when the implantable device is run using battery 74 alone.Such parameters may include motor speed and voltage, duration/number ofrevolutions of the motor shaft when alternating between forward andreverse directions, etc.

User interface block 185 handles display of information retrieved fromthe monitoring and control system and implantable device via datadownload block 183, and presents that information in an intuitive,easily understood format for physician review. As described below withrespect to FIGS. 10 to 14, such information may include status of theimplantable device, status of the charging and control system, measuredpressures, volume of fluid transported per pumping session or per day,etc. User interface block 185 also generates user interface screens thatpermit the physician to input information to configure the intervaltiming, limit and pump operation parameters discussed above with respectto block 184.

Alarm detection block 186 may include a routine for evaluating the dataretrieved from the implantable device or charging and communicationsystem, and flagging abnormal conditions for the physician's attention.For example, alarm detection block 186 may include health monitor block191, which is configured to alert the physician to any changes in thepatient's health that may warrant changing the volume, time, and/orfrequency with which the DSR infusate is provided to the patient'speritoneal cavity. For example, if data provided by the implantabledevice 20 indicate a buildup of fluid in the peritoneal cavity, then thephysician may increase the volume, time, and/or frequency with which thefluid is withdrawn from the patient's peritoneal cavity. Or, if dataprovided by the implantable device 20 indicate a relatively low volumeof fluid, then the physician may decrease the volume, time, and/orfrequency with which the fluid is withdrawn from the patient'speritoneal cavity.

Alarm detection block 186 also, or alternatively, may includedecompensation prediction block 192, which is configured to predict ordetect heart failure decompensation based on, for example, one or moreof an increase in the accumulation of fluid in the patient's peritonealcavity above a predefined threshold, an increase in the patient'srespiratory rate above a predefined threshold, and/or an increase in theintraabdominal pressure above a predefined threshold. Such flags may becommunicated to the physician by changing status indicators presented byuser interface block 185, or by displaying to the physician specificinformation about increases in the patient's fluid accumulation,respiratory rate, or intraabdominal pressure via user interface block185.

Sensor calibration block 187 may include a routines for testing ormeasuring drift, of sensors 70, 78-81 employed in the implantabledevice, e.g., due to aging or change in humidity. Block 187 may thencompute offset values for correcting measured data from the sensors, andtransmit that information to the implantable device for storage innonvolatile memory 71. For example, pressure sensors 104 a-104 d mayexperience drift due to aging or temperature changes. Block 187accordingly may compute offset values that are then transmitted andstored in the implantable device to account for such drift.

Firmware upgrade block 188 may comprise a routine for checking theversion numbers of the processor or motor controller firmware installedon the implantable device and/or processor firmware on charging andcommunication system, and identify whether upgraded firmware exists. Ifso, the routine may notify the physician and permit the physician todownload revised firmware to the implantable device for storage innonvolatile memory 71 or to download revised firmware to the chargingand communication system for storage in nonvolatile memory 153.

Device identifier block 189 consists of a unique identifier for theimplantable device that is stored in nonvolatile memory 71 and a routinefor reading that data when the monitoring and control system is coupledto the implantable device via the charging and communication system. Asdescribed above, the device identifier is used by the implantable deviceto confirm that wireless communications received from a charging andcommunication system are intended for that specific implantable device.Likewise, this information is employed by handpiece 151 of the chargingand communication system in determining whether a received message wasgenerated by the implantable device associated with that handpiece.Finally, the device identifier information is employed by monitoring andcontrol software 180 to confirm that the handpiece and implantabledevice constitute a matched set.

Status information block 190 comprises a routine for interrogatingimplantable device, when connected via handpiece 151, to retrievecurrent status date from the implantable device, and/or handpiece 151.Such information may include, for example, battery status, the date andtime on the internal clocks of the implantable device and handpiece,version control information for the firmware and hardware currently inuse, and sensor data.

Referring now to FIGS. 10-14, exemplary screen shots generated by userinterface block 187 of software 180 are described for an implantablesystem used in accordance with the methods of the present invention totreat HF. FIG. 10 shows main screen 200 that is displayed to a physicianrunning monitoring and control software 180. Main screen 200 includes astatus area that displays status information retrieved from theimplantable device and the charging and communication system by theroutine corresponding to block 190 of FIG. 9. More particularly, thestatus area includes status area 201 for the charging and communicationsystem (referred to as the “Smart Charger) and status area 202 for theimplantable device (referred to as the “ALFA Pump”). Each status areaincludes an icon showing whether the respective system is operatingproperly, indicated by a checkmark, the device identifier for thatsystem, and whether the system is connected or active. If a parameter isevaluated by the alarm detection block 186 to be out of specification,the icon may instead include a warning symbol. Menu bar 203 identifiesthe various screens that the physician can move between by highlightingthe respective menu item. Workspace area 204 is provided below thestatus area, and includes a display that changes depending upon the menuitem selected. Below workspace area 204, navigation panel 205 isdisplayed, which includes the version number of software 180 and a radiobutton that enables the displays in workspace area 204 to be refreshed.

In FIG. 10, the menu item “Information” with submenu item “Implant” ishighlighted in menu bar 203. For this menu item selection, workspacearea 204 illustratively shows, for the implantable device, batterystatus window 204 a, measured pressures window 204 b and firmwareversion control window 204 c. Battery status window 204 a includes anicon representing the charge remaining in battery 74, and may bedepicted as full, three-quarters, one-half, one-quarter full or show analarm that the battery is nearly depleted. The time component of window204 a indicates the current time as received from the implantabledevice, where the date is expressed in DD/MM/YYYY format and time isexpressed in HR/MIN/SEC format based on a 24 hour clock. Measuredpressures window 204 b displays the bladder pressure, peritonealpressure and ambient pressures in mBar measured by sensors 104 a, 104 band 104 d respectively (see FIG. 6A). Version control window 204 cindicates the firmware version for processor 70, for the motorcontroller, and the hardware version of the implantable device. Patientparameters window 204 d displays the patient's temperature, respiratoryrate, and intraabdominal pressure. Note that if implantable deviceincluded other types of sensors, e.g., sensors that measure the levelsof fluid in the body, then the parameters measured by such sensors couldalso be displayed in window 204 d.

Alarm condition window 204 e displays any changes in parameters that mayindicate a change in the patient's health, such as the possibledevelopment of heart failure decompensation or an improvement orworsening of the patient's health (Blocks 191 and 192 in FIG. 9). Forexample, as illustrated, alarm condition window 204 e may alert thephysician that the patient's intra-abdominal pressure is abnormallyhigh, so that the physician then may follow up with the patientregarding the possibility of decompensation. In some embodiments, basedon information displayed in windows 204 b, 204 d, and/or 204 e, thephysician may adjust the operating parameters of the pump, e.g., usingthe interface described further below with reference to FIG. 13.

Turning to FIG. 11, screen display 206 corresponding to selection of the“Smart Charger” submenu item in FIG. 10 is described. FIG. 11 includesstatus area 201 for the charging and communication system, status area202 for the implantable device, menu bar 203, workspace area 204, andnavigation panel 205 as discussed above with respect to FIG. 10. Screendisplay 206 differs from screen display 200 in that the “Smart Charger”submenu item is highlighted, and workspace area 204 displays, for thecharging and control system, battery status window 207 a and versioncontrol window 207 b. Battery status window 207 a includes an iconrepresenting the charge remaining in battery 157, and may be depicted asfull, three-quarters, one-half, one-quarter full or show an alarm thatthe battery is nearly depleted. The time component of window 207 aindicates the current time as received from handpiece 151, where thedate is expressed in DD/MM/YYYY format and time is expressed inHR/MIN/SEC format based on a 24 hour clock. Version control window 207 bindicates the firmware version for processor 152, and the hardwareversion of the charging and control system.

Referring now to FIG. 12, screen display 208 corresponding to selectionof the “Download” menu item in FIG. 10 and “Log Files” submenu item isdescribed, and implements the functionality of block 183 of software180. FIG. 12 includes status area 201 for the charging and communicationsystem, status area 202 for the implantable device, menu bar 203,workspace area 204, and navigation panel 205, all as discussed above.Screen display 208 differs from the “Information” screen display in thatthe “Log Files” submenu item is highlighted, and workspace area 204displays download progress window 209 a and storage path window 209 b.Window 209 a includes the path for the directory to which event logs maybe downloaded from the implantable device via the charging andcommunication system. Window 209 a also includes an “Open DownloadFolder” radio button that allows the physician to choose the directorypath to which the event logs are downloaded, and a progress bar that isupdated to reflect the amount of data downloaded. Window 209 b includesa radio button that can be activated to download the event log to thepath specified in window 209 a, and also includes an “Abort” radiobutton to interrupt the download process.

FIG. 13 is an exemplary depiction of screen display 210, correspondingto selection of the “Pump Settings” menu item in FIG. 10 and “FluidTransport” submenu item, and implements the functionality of blocks 184and 190 of software 180. FIG. 13 includes status area 201 for thecharging and communication system, status area 202 for the implantabledevice, menu bar 203, workspace area 204, and navigation panel 205, allas discussed above. Screen display 210 differs from the “Information”screen displays in that the “Fluid Transport” submenu item ishighlighted, and workspace area 204 includes session volume window 211a, fluid transport program window 211 b, minimum daily volume window 211c, pressure window 211 d, and a radio button in navigation panel 205that permits values entered in windows 211 a, 211 b and 211 d to betransmitted and stored in nonvolatile memory 71 of the implantabledevice.

Session volume window 211 a displays the current setting for theinterval time between pumping sessions of the fluid that naturallyaccumulates in the peritoneal cavity, the times of the day that the pumpmay be activated, the total daily pump time and the session volume perpumping session. The dwell time displayed in window 211 a allows thephysician to set the amount of time that the DSR infusate is to remainin the peritoneal cavity. The interval time displayed in window 211 aallows the physician to set the frequency with which the sodium-ladenDSR infusate and osmotic ultrafiltrate are extracted from the peritonealcavity and directed to the bladder (as well as the DSR infusate from thereservoir to the peritoneal cavity). The volume of DSR infusatedelivered from the reservoir, dwell times and extraction times are usedby the configuration setup routine (block 184 of FIG. 9) to determineoverall operation of the system.

The time segments that the pump may be active, displayed in window 211a, optionally may be used define the timeframes during which theimplantable device can actively move fluid to the bladder; outside ofthese time segments, the implantable device will not move fluid but mayimplement the pump tick operation described above to turn the gears on aregular basis to prevent clogging of the gears. Depending on theperceived health of the patient, the physician may set the time segmentssuch that the pump may operate at all hours of the day or night, aspreservation of health may override convenience in some circumstances.The daily pump time displayed in window 211 a is shown in read-onlyformat because it is the aggregate of the time segments entered in thetime segments boxes. Finally, the session volume displayed in window 211a is computed by block 183 as the amount of fluid transferred to thebladder in a single pumping session.

Fluid transport program window 211 b displays the status of the programcontrolling operation of the pump of the implantable device based on theparameters set using block 184 of software 180. In case pump activitymust be stopped for any reason, the fluid transport program can bestopped by clicking the “Off” button in window 211 b, which will causethe pump to stop pumping until it is manually switched back on. In oneembodiment, the fluid transport program may switched on again bypressing the “On” button in window 211 b. Because the implantable devicepreferably is implanted with the pump turned off, the physician orsurgeon may use window 211 b to turn on the fluid transport programafter the implantable device is first implanted.

Minimum daily volume window 211 c displays the expected amount of fluidto be pumped to the bladder by the implantable device, and is computedby the configuration setup routine as the session volume times thenumber of sessions per day, based on the length of the prescribed timesegments and interval timing input in window 211 a.

Pressure window 211 d of FIG. 13 permits the physician to input valuesof maximum bladder pressure and minimum peritoneal pressure that areused to control operation of the implantable pump. Thus, for example,processor 70 will command motor 73 to cease a current pumping session,or to skip a planned pumping session during the time segments identifiedin window 211 a, if the bladder pressure detected by the pressuresensors exceeds the value specified in window 211 d. Likewise, processor70 will command motor 73 to cease a current pumping session, or to skipa planned pumping session during the time segments identified in window211 a, if the peritoneal pressure detected by the pressure sensors isless than the value specified in window 211 d. If configured to operatein the above-described manner, the implantable device will neither causepatient discomfort by overfilling the patient's bladder, nor cause theperitoneal cavity to become excessively dry.

Referring now to FIG. 14, an exemplary depiction of screen display 212,corresponding to selection of the “Test” menu item in FIG. 11 and“Manual Test Run” submenu item is described. FIG. 14 includes statusarea 201 for the charging and communication system, status area 202 forthe implantable device, menu bar 203, workspace area 204, and navigationpanel 205, all as discussed above. Screen display 212 differs from the“Information” screen displays in that the “Manual Test Run” submenu itemis highlighted, and workspace area 204 includes manual pump cycle window213. Manual pump cycle window 213 includes radio button “Start Test”which transmits a command to the implantable device via the charging andcommunication system to cause processor 70 to activate the pump for apredetermined period of time, e.g., a few seconds. Processor 70 receivespositional data from the Hall Effect sensors in motor 73 and measuredpressure data across pressure sensors 104 c and 104 d. Processor 70computes a session volume and relays that information via the chargingand communication system back to software 10, which compares themeasured data to a target session volume and provides a test result,e.g., percentage of session target volume achieved or pass/fail icon.The measured session volume, session target volume and test result aredisplayed in window 213.

While various illustrative embodiments of the invention are describedabove, it will be apparent to one skilled in the art that variouschanges and modifications may be made therein without departing from theinvention. For example, system 10 may be modified to include additionaldevices configured to assess the physical and/or mental health of thepatient, such as weighing scales, ECG or heart-rate sensors or ahand-held biosensor that measures the levels of sodium and/or toxinsand/or waste products, e.g., ammonia, c-reactive protein, plasma renin,serum sodium, serum creatinine, prothrombin time, and/or bilirubin, in adrop of the patient's blood. If coupled to sensor that measures serumcreatinine, the system may be configured to calculate and store acurrent value of GFR using the equation set forth above. If soconfigured, the system could issue an alert to the physician todiscontinue the use of no or low sodium DSR infusate if the GFR iscomputed to fall below 15.

Alternatively, or in addition, system 10 may be modified to include ahand-held or computer-based device that presents the patient withpsychometric tests that measure the psychological health orelectrophysiological activity of the subject. Such devices may beconfigured to wirelessly provide results to monitoring and controlsystem 40 for the physician to use in assessing the patient's health andthe possible need to adjust the operating parameters of implantabledevice 20. The appended claims are intended to cover all such changesand modifications that fall within the true spirit and scope of theinvention.

Preliminary Experimental Results

Initial testing of the DSR infusate and methods of the present inventionhas been conducted in a porcine model, which is expected to providevalid insights into how the inventive system, methods and DSR infusatewill behave in humans. That initial testing has provided remarkablysuccessful and beneficial results that far exceeded expectations, asdescribed in further detail below.

In a first group of five pigs (“protocol refinement pigs”), the effectof infusing 1 liter of sodium-free DSR infusate into the peritonealcavity of each pig was measured. The DSR infusate generally comprisedpurified water and dextrose, e.g., 10 grams per 100 ml of water, and wasallowed to dwell in their peritoneal cavities for up to six hours. 5-25micro curies of I-131 radiolabled albumin was mixed into the infusate asa non-absorbable tracer to determine ultrafiltration kinetics withoutrequiring serial drains of the abdomen. Throughout the dwell period, thefluid in the peritoneal cavities was sampled to determine total sodiumremoved and sodium concentration in the fluid accumulating in theperitoneal cavity as a function of time, and blood samples were taken aswell. Specifically, in the 1½ hours after infusion of the DSR infusate,3 ml blood sample and 2.5 ml fluid samples were taken every 15 minutesand analyzed. In the next 1½ hour period, blood and fluid samples weretaken every ½ hour. And in the final 3 hours, additional blood and fluidsamples were taken every hour. In addition, the total volume of fluidaccumulated in the peritoneal cavity, consisting of sodium-laden DSRinfusate and osmotic ultrafiltrate, was recorded as a function of time.

FIG. 15A shows the total amount of sodium removed as a function of dwelltime for the first group of pigs, while FIG. 15B shows the sodiumconcentration in the samples removed from the peritoneal cavities as afunction of time. FIG. 15C depicts the total volume of fluid accumulatedin the peritoneal cavities of the first group of pigs. As depicted inFIG. 15C, surprisingly, after two hours, infusion of 1 liter of DSRinfusate induced 1 liter of osmotic filtrate to accumulate in theperitoneal cavity.

In a second group of ten pigs (“protocol pigs”), 1 liter of DSR infusatewas infused in the peritoneal cavities of each pig for a two hour dwellperiod. Throughout the dwell period serum sodium, serum osmolality,plasma osmolality and glucose levels of the pigs were periodicallymeasured by taking 6 ml blood samples every ½ hour. Total osmolality,glucose osmolality and non-glucose osmolality of the fluid accumulatingin the peritoneal cavities were periodically measured during the dwellperiod using the foregoing samples. After completion of the dwellperiod, the total volume of fluid drained from the peritoneal cavity andthe total amount of sodium removed, was measured.

FIG. 16A is a chart showing the total fluid volume removed from theperitoneal cavity of each protocol pig after a two-hour dwell. FIG. 16Bshows the total amount of sodium removed from the peritoneal cavity ofeach protocol pig after a two-hour dwell. FIG. 16C shows the evolutionof total osmolality, glucose osmolality, and non-glucose osmolality forsamples of fluid from the peritoneal cavities of the protocol pigsthroughout the two-hour dwell period. FIGS. 16D, 16E and 16F show theevolution of serum sodium, serum osmolality, and serum glucose,respectively, for the protocol pigs throughout the two-hour dwellperiod. The foregoing results demonstrate that the inventive DSR methodsand infusates remove a clinically relevant amount of sodium, e.g., 4000mg, with a single administration of 1 liter of DSR infusate and a twohour dwell, but with clinically negligible impact on serum sodiumlevels. The 4000 mg of sodium removed is generally equivalent to twodays of recommended sodium consumption, which will induce theelimination of stored fluid via urination and direct removal of asignificant (1 liter with the studied parameters) accumulation ofosmotic ultrafiltrate from the peritoneal cavity. And as shown in FIGS.16D, 16E and 16F, the single administration of DSR infusate with a twohour dwell is expected to be very safe, as serum sodium level and serumosmolality remained stable throughout the period with only an expectedand clinically manageable increase of serum glucose concentration.

FIGS. 17A-17C depicts the measurements for a number of blood volumemarkers in a sub-group of five of the protocol pig population bothbefore and after repeated application of the inventive methods. FIG. 17Ashows almost a ½ reduction in the total blood volume of the protocolpigs after five cycles of DSR treatment. As expected, FIG. 17B showsvirtually no impact of the DSR method on the total volume of red bloodcells. However, FIG. 17C shows that there is a reduction in plasmavolume of approximately 60%. Accordingly, as depicted in FIGS. 17A-17C,repeated use of the DSR method of the present invention is demonstratedto achieve a significant reduction in blood volume by reducing plasmavolume. This demonstrates the effectiveness of the DSR method of thepresent invention and how it may be used to eliminate different levelsof fluid overload.

FIG. 18 shows the impact on serum sodium concentration in the samesub-group of five of the protocol pigs to investigate the impact of useof the inventive DSR infusate in patients with reduced residual renalfunction was conducted. As shown in FIG. 18, serial application of themethod of the present invention without the pigs having an opportunityto restore the loss of sodium and fluid lead to severe reductions inserum sodium levels. The pigs were effectively anephric due to thesevere renal injury from blood volume depletion. FIGS. 17A-C and FIG. 18suggest that use of a no or low sodium infusate in patients with severerenal dysfunction (i.e. CKD of Stage 5 or GFR<15 ml/min/1.73 m²) involumes adequate for dialysis would lead to dangerous or terminalhyponatremia and reduction in plasma volume leading to hemodynamiccollapse. Accordingly, as described above, the DSR method, infusate andapparatus of the present invention should be targeted to those patientsexperiencing fluid overload and heart failure who still have a GFR valuegreater than 15 or CKD of Stage 4 or lower.

While various illustrative embodiments of the invention are describedabove, it will be apparent to one skilled in the art that variouschanges and modifications may be made therein without departing from theinvention. For example, pump system 1 may be ordered differently and mayinclude additional or fewer components of various sizes and composition.The appended claims are intended to cover all such changes andmodifications that fall within the true spirit and scope of theinvention.

What is claimed is:
 1. A method of using a no or low sodium DSR infusateto treat a patient in heart failure with fluid overload, the patienthaving an estimated glomerular filtration rate greater than 15ml/min/1.73 m², the method comprising: introducing a DSR infusate havingno or low sodium into a peritoneal cavity of the patient; inducingsodium and osmotic ultrafiltrate to accumulate with the DSR infusate inthe peritoneal cavity during a dwell period; removing the DSR infusate,sodium and osmotic ultrafiltrate from the peritoneal cavity of thepatient to alleviate fluid overload, while preventing hyponatremia. 2.The method of claim 1, further comprising eliminating fluid from thepatient through urination caused by kidney functioning.
 3. The method ofclaim 1, wherein introducing a DSR infusate having no or low sodium intoa peritoneal cavity of the heart failure patient comprises introducing aDSR infusate having a sodium concentration less than 120 meq/L.
 4. Themethod of claim 1, wherein introducing a DSR infusate having no or lowsodium comprises introducing a DSR infusate having dextrose orIcodextrin or combinations thereof.
 5. The method of claim 1, whereinintroducing a DSR infusate having no or low sodium into a peritonealcavity of the patient comprises transferring the DSR infusate into theperitoneal cavity of the patient from a reservoir using an implantablepump.
 6. The method of claim 1, wherein introducing a DSRinfusate havingno or low sodium into a peritoneal cavity of the patient comprisesinfusing the DSR infusate into the peritoneal cavity of the patientusing gravity to deliver the DSR infusate from a reservoir.
 7. Themethod of claim 1, wherein introducing a DSR infusate having no or lowsodium into the peritoneal cavity of a patient comprises delivering theDSR infusate using an extracorporeal pump, pressurized container, orgravity based feeding system.
 8. The method of claim 1, wherein removingthe DSR infusate including the sodium and osmotic ultrafiltrate from theperitoneal cavity of the patient comprises, upon expiration of the dwellperiod, transferring the DSR infusate, sodium and osmotic ultrafiltratefrom the peritoneal cavity to a urinary bladder of the patient using animplantable pump.
 9. The method of claim 8, further comprisingactivating the implantable pump at predetermined times to transfer apredetermined volume of the DSR infusate, sodium and osmoticultrafiltrate from the peritoneal cavity to the urinary bladder of thepatient.
 10. The method of claim 1, further comprising monitoring theintra-abdominal pressure of the patient with one or more sensors. 11.The method of claim 10, further comprising monitoring the rate of fluidaccumulation in the peritoneal cavity.
 12. The method of claim 11,further comprising generating an alert to a physician indicative of theincrease in the rate of fluid accumulation in the peritoneal cavity orincrease in intra-abdominal pressure.
 13. A method of using a no or lowsodium solution to treat a patient in heart failure with fluid overload,the patient having kidney function from normal to CKD Stage 4, themethod comprising, introducing a DSR infusate having no or low sodium toa peritoneal cavity of the patient; inducing sodium and osmoticultrafiltrate to accumulate with the DSR infusate in the peritonealcavity during a dwell period; removing the DSR infusate, sodium andosmotic ultrafiltrate from the peritoneal cavity to alleviate the fluidoverload; and removing fluid from patient by urination to restore serumsodium concentrations, while preventing hyponatremia.
 14. The method ofclaim 13, wherein introducing a DSR infusate having no or low sodium toa peritoneal cavity of the patient comprises introducing a DSR infusatesolution having a sodium concentration less than 120 meq/L.
 15. Themethod of claim 14, wherein introducing a DSR infusate having no or lowsodium to the peritoneal cavity of the patient comprises introducing aDSR infusate having a dextrose concentration in a range of 5 to 50 gmper 100 ml aqueous solution, icodextrin in a range of 5 to 50 gm per 100ml aqueous solution, or combination thereof.
 16. The method of claim 13,wherein introducing a DSR infusate having no or low sodium into aperitoneal cavity of the patient comprises transferring the DSR infusateinto the peritoneal cavity of the patient from a reservoir using animplantable pump.
 17. The method of claim 13, wherein introducing a DSRinfusate having no or low sodium into a peritoneal cavity of the patientcomprises infusing the DSR infusate into the peritoneal cavity of thepatient using gravity to deliver the DSR infusate from a reservoir. 18.The method of claim 13, wherein introducing a DSR infusate having no orlow sodium into the peritoneal cavity of a patient comprises deliveringthe DSR infusate using an extracorporeal pump, pressurized container orgravity-based feeding system.
 19. The method of claim 13, whereinremoving the DSR infusate, sodium and osmotic ultrafiltrate from theperitoneal cavity of the patient comprises, upon expiration of the dwellperiod, transferring the DSR infusate, sodium and osmotic ultrafiltratefrom the peritoneal cavity to a urinary bladder of the patient using animplantable pump.
 20. The method of claim 19, further comprisingactivating the implantable pump at predetermined times to transfer avolume of the DSR infusate, sodium and osmotic ultrafiltrate from theperitoneal cavity to the urinary bladder of the patient.
 21. The methodof claim 13, further comprising monitoring an intra-abdominal pressureof the patient with one or more sensors.
 22. The method of claim 21,further comprising monitoring the rate of fluid accumulation in theperitoneal cavity.
 23. The method of claim 23, further comprisinggenerating an alert to a physician indicative of the increase in therate of fluid accumulation in the peritoneal cavity or increase inintra-abdominal pressure.